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MECHANICAL  THEEAPEUTICS. 


A 


PRACTICAL  TREATISE 

ON 

SURGICAL  APPARATUS,  APPLIANCES, 

AND 

ELEMENTARY  OPERATIONS; 

EMBRACING 

\ 

BANDAGING,  MINOR  SURGERY,  ORTHOPRAXY,  AND  THE 
TREATMENT  OF  FRACTURES  AND  DISLOCATIONS. 


BY 

PHILIP  S.  WALES,  M.D.,  Surgeon  U.S.N. 

Y/ITH  SIX  HUNDRED  AND  FORTY-TWO  ILLUSTRATIONS. 


PHILADELPHIA: 

H E I E Y 0.  LEA. 
1867. 


X 

\a)ck  ies 


Entered  according  to  the  Act  of  Congress,  in  the  year  1867,  by 
HENRY  C.  LEA, 

in  the  Office  of  the  Clerk  of  the  District  Court  of  the  United  States  in  and  for  the 
Eastern  District  of  the  State  of  Pennsylvania. 


PHILADELPHIA  : 

COLLINS,  PRINTER,  705  JaTNE  STREET. 


PREFACE. 


Pv  offering  to  the  profession  the  present  volume  on  mechanical 
therapeutics,  the  author  would  state  that  his  design  is  to  place  in  the 
hands  of  students  and  practitioners  of  medicine  a systematized  and  con- 
densed description  of  surgical  dressings,  apparatus,  and  elementary 
operations,  drawn  from  the  writings  and  teaching  of  the  ablest  sur- 
geons in  America  and  Europe.  In  its  preparation  care  has  been  taken 
to  adapt  it  also  to  the  necessities  of  those  wishing  to  enter  the  public 
service,  inasmuch  as  the  rigid  and  thorough  examinations  of  our 
Military  and  ISTaval  Medical  Boards  require  more  minute  and  ex- 
tended information  upon  these  subjects  than  can  be  obtained  from 
the  ordinary  text-books. 

The  author  has  availed  himself  of  the  advantages  offered  him  in 
hospital  'and  private  practice,  and  has  submitted  to  actual  trial  most  of 
the  plans  of  treatment  described  in  the  work,  noting  at  the  time  their 
advantages  and  disadvantages  in  the  cases  in  which  they  have  been 
recommended  by  their  authors.  All  embarrassing  generalities  have 
been  avoided  as  far  as  possible  in  the  descriptions,  each  step  in  the 
preparation  and  application  of  apparatus  being  minutely  detailed. 

In  a work  of  this  nature  it  was  indispensable  for  the  easy  under- 
standing of  the  subjects  treated  that  it  should  be  fully  illustrated. 
Many  engravings  introduced  throughout  the  volume  have  been  drawn 
from  the  well-known  works  of  Yelpeau,  Gross,  Miller,  Erichsen,  Fer- 
gusson,  Druitt,  Skey,  Pirrie,  and  Sargent;  while  the  author  would 
also  acknowledge  special  indebtedness  to  the  elaborate  treatises  of 
Hamilton,  Malgaigne,  and  E.  It.  Smith,  on  fractures  and  dislocations ; 


27019 


IV 


PREFACE. 


to  Goffres’  “ Precis  des  Bandages,  Pansements  et  Appareils,”  Jamain's 
“ Manuel  de  Petite  Chirurgie,”  and  to  Bigg’s  Orthopraxy. 

The  skilful  surgical  mechanicians,  Mr.  Kolbe  and  Mr.  Gemrig,  of 
Philadelphia,  have  been  courteous  enough  to  place  at  his  disposal 
models  and  drawings  of  the  latest  surgical  apparatus  and  appliances. 

Philadelphia,  Nov.  1867. 


CONTENTS 


PART  I . 

OF  THE  “APPARATUS  OF  DRESSING.” 
CHAPTER  I. 


OF  THE  INSTRUMENTS  OF  DRESSING. 


The  Pocket-Case 

PACE 

. 83 

Porte-meche  . 

PAOE 

. 42 

Scalpels 

. 33 

Directors 

. 42 

Bistouries 

. 34 

Spatulas  .... 

. 42 

Scissors  . 

. 35 

Porte-caustic  . 

. 42 

Razor 

. 36 

Surgical  Needles 

. 43 

Forceps  . 

. 37 

Trocars  .... 

. 43 

Tenaculum 

. 40 

Catheters 

. 44 

Lancets  . 

. 40 

Ivory  'winder  for  suture  threads 

. 44 

Probes 

. 41 

CHAPTER  II. 

OF  THE  FIRST  PIECES  OF  DRESSING. 


Lint 

44 

Sawdust  . 

51 

Charpie  . 

45 

Metallic  Plates 

51 

Different  Forms  of  Charpie 

46 

Compresses 

51 

Sponge  Tent 

47 

Simple 

52 

Cotton 

48 

Splint  . 

52 

Oakum  . 

49 

Folded 

54 

Tow 

49 

Knots 

55 

Wool 

49 

Adhesive  Plaster 

56 

Raw  Silk 

49 

Isinglass  Plaster 

58 

Sponge  . 

50 

Collodion 

58 

Moss 

50 

Styptic  Colloid 

59 

Cat’s-Tail 

50 

The  Surgical  Tray  . 

61 

Amadou  . 

50 

The  Surgical  Wallet 

61 

Bran 

51 

CHAPTER  III. 

ON  THE 

USE 

OF 

SOME  TOPICAL  REMEDIES. 

Cerates  . 

62 

Lotions  . 

72 

Ointments 

64 

Collyria  . 

74 

Plasters  . 

67 

Gargles  . 

77 

Liniments 

69 

Collutories 

78 

Glycerine 

70 

Poultices 

79 

VI 


CONTENTS. 


CHAPTER  IY. 

ON  THE  USE  OF  WATER  IN  SURGICAL  DISEASES  AND  INJURIES. 


PAGE 


Sect.  I.  Water  as  a Surgical  Dressing 



86 

Cold  Water-dressings 

. 87 

Irrigation — 

Warm  Water-dressings  . 

. 88 

Warm  ...... 

93 

Medicated  Water-dressings 

. 89 

Of  the  Nasal  Fossae 

93 

Dry  Fomentation 

. 89 

Of  the  Bladder  .... 

94 

Immersion  .... 

. 89 

Of  the  Uterus  and  Vagina  . 

94 

Irrigation  .... 

. 90 

The  Application  of  Water  by  Means 

Cold 

. 92 

of  India-rubber  Sacks 

95 

Sect.  II.  The  Use  of  Water  Generally — Bathing 

98 

General  Baths 

. 98 

Local  Baths  ..... 

98 

CHAPTER  Y. 


INJECTIONS. 


Injection 

. 106 

Injection  of  the  Vagina 

Of  the  Lachrymal  Duct 

. 107 

Of  the  Uterus 

Of  the  Ear  . 

. 107 

Of  tlie  Rectum 

Of  the  Urethra 

. 109 

Of  the  Cellular  Tissue 

Of  the  Bladder 

. 110 

Of  Abnormal  Canals 

CHAPTER  YI. 


110 

111 

112 

115 

116 


ON  THE  USE  OF  GASES  AND  VAPORS. 

Sect.  I.  Purification  of  the  Air  of  Hospitals  and  Chambers,  or  Disinfection  117 
Sect.  II.  The  Application  of  Vapors  and  Gases  to  the  Skin,  or  Fumigation  . 123 

Sect.  III.  The  Application  of  Gases,  Vapors,  and  Atomized  Liquids  to  the  In- 
terior Cavities  ............  126 


CHAPTER  VII. 

THE  “SECOND  PIECES”  OF  DRESSING,  OR  BANDAGES  PROPERLY  SO  CALLED. 
Sect.  I.  General  Rules  for  the  Preparation  and  Application  of  Bandages  . 131 


Sect.  II.  Special  Systems  of  Bandaging 137 

Mayor’s  .....  137  I Rigal’s  ......  137 

Sect.  III.  The  Indications  Answered  by  Bandages 139 

Sect.  IV.  Classification  of  Bandages 15S 


CHAPTER  VIII. 


SPECIAL  OR  REGIONAL  BANDAGING. 


Sect.  I.  Bandages  for  the  Head 
Simple  Bandages  . 

. 160 

Simple  Bandages — 

. 159 

Circular  Bandages 

160 

Crossed  Bandages 

. 162 

Of  the  Forehead  and  Eyes 

160 

The  Monocle 

. 162 

CONTENTS. 


YU 


Simple  Bandages — 

The  Binocle  ....  162 

Single  Crossed  Bandage  for  the 
Lower  Jaw  ....  163 

Double  Crossed  Bandage  for  the 
Lower  Jaw  ....  163 

Crossed  Bandage  of  the  Head  . 165 

Crossed  Bandage  of  the  Head 
and  Neck  ....  165 

Knotted  Bandages  . . . 165 

Knotted  Bandage  of  the  Head  . 165 

Recurrent  Bandages  . . .166 

Recurrent  Bandage  of  the  Head  166 
Handkerchief  Bandages  . .167 

Triangular  Bandage  of  the  Head  167 
Quadrilateral  Bandage  of  the 

Head 167 

Invaginated  Bandages  . .167 

Invaginated  Bandage  of  the  Lips  167 

Compound  Bandages  . . .168 

T Bandages 168 

T Bandage  of  the  Head  and  Ears  168 
Double  T Bandage  of  the  Nose  . 168 

T Bandage  of  the  Head  . .168 

Double  T Bandage  of  the  Head  . 168 

T Bandage  of  the  Mouth  . . 169 

Crucial  Bandages  . . .169 

Crucial  Bandage  of  the  Head  . 169 


Compound  Bandages — 

Sling  Bandages  .... 
Six-Tailed  Bandage  of  the  Head 
Four-Tailed  Bandage  of  the  Chin 
Mask  .... 
Sheath  Bandages  . 

Sheath  Bandage  of  the  Nose 
Sheath  Bandage  of  the  Tongue 

Mayor’s  Bandages  . 

Circular  Cravat  . 

Occipito-Frontal  Triangle 
Fronto-Occipital  Triangle 
Fronto-Oculo-Occipital  Triangle 
Bis-Oculo-Occipital  Triangle 
Occipito-Mental  Triangle 
Fronto-Cervico-Labial  Triangle 
Facial  Triangle 
Occipito-Auricular  Triangle 


Rigal’s  Bandages 
Cap 

Half-Cap 
Simple  Capeline 
Fixed  Capeline 
Arabic  Capeline 
Shepherd’s  Sling 
Ocular  Triangle 


169 

170 

170 

171 
171 
171 

171 

172 
172 

172 
172 
172 
172 

173 
173 
173 
173 

173 

173 

173 

174 
174 
174 
174 
174 


Sect.  II.  Bandages  of  the  Neck  and  Trunk 


Simple  Bandages  .... 

Circular  Bandages 
Circular  of  the  Neck 
Circular  of  the  Chest  and  Abdo- 
men ..... 

Oblique  Bandages 
Oblique  Bandages  of  the  Neck 
and  Axilla  .... 

Spiral  Bandages  .... 
Spiral  Bandages  of  the  Body  . 

Crossed  Bandages 
Posterior  Figure  of  8 of  the  Head 
and  Axillas  .... 
Anterior  Figure  of  8 of  the  Head 
and  Axillas  .... 
Figure  of  8 of  the  Head  and  One 
Axilla  ..... 
Figure  of  8 of  the  Neck  and 
Axilla  ..... 


176 

176 

176 

176 

177 

177 

177 

177 

177 

177 

178 
178 


17S 


Simple  Bandages — 

The  Spica  or  Figure  of  8 of  the 
Shoulder  and  Opposite  Axilla 
Anterior  Figure  of  8 of  the 
Shoulders  .... 
Posterior  Figure  of  8 of  the 
Shoulders  .... 
Crossed  Bandage  of  the  Chest  . 
Of  One  Breast 
Of  Both  Breasts  . 

Of  One  Groin 
Of  Both  Groins 

Compound  Bandages 

T Bandages  .... 
Double  T of  the  Chest  and  Ab- 
domen ..... 
Anterior  Double  T of  the  Head 
and  Chest  .... 


175 


179 

180 

180 

180 

181 

182 

182 

183 

1S3 

183 

183 

184 


M 8 


19 


Till 


CONTENTS. 


Compound  Bandages — 


PAGE 


Mayor’s  Bandages — 


PAGE 


Posterior  Double  T of  the  Head 
and  Chest  ....  184 

Double  T of  the  Pelvis  . . 184 

T Bandage  of  the  Groin  . . 184 

The  Crossed  Bandage  of  the  Trunk  185 
Sling  Bandages  ....  185 

Of  the  Shoulder  . . . 185 

Of  the  Breast  ....  185 

Of  the  Hip  ...  186 

Suspensory  Bandages  . . . 186 

Of  the  Breast  ....  186 

Of  the  Testicle  . . . 1S7 

Sheath  Bandages  . . . 187 

Of  the  Penis  ....  187 


Simple  Dorso-Bis-Axillary  Cravat  189 
Compound  Dorso-Bis-Axillary  Cra- 
vat   189 

Cravat,  Triangle,  and  Squares  . 189 

Triangular  Cap  of  the  Breast  . 189 

Cervico-Thoracic  Cravat  . . 189 

Cervico-Dorso-Sternal  Cravat  . 189 

Sacro-Puhic  Triangle  . . . 189 

Intercrural  Cravat  . . . 190 

Cruro-Pelvic  Triangle  . . . 1-90 

Cruro-Pelvic  Cravat  . . . 190 

Sacro-Bi-Crural  Cravats  . . 190 

Sacro-Lumbar  Triangle  . . 190 

Coxo-Pelvic  Triangle  . . .190 


Mayor's  Bandages  for  the  Neck  and 


Trunk 187 

Cravat  of  the  Neck  . . . 187 

Occipito-Thoracic  Triangle  . .187 

Fronto-Tlioracic  Triangle  . . 188 

Parieto-Axillary  Triangle  . . 188 

Thoracico-Scapular  Triangle  . 188 

Simple  Bis-Axillary  Cravat  . . 188 

Compound  Bis-Axillary  Cravat  . 188 


Rigal’s  Bandages  for  the  Neck  and 


Trunk  .... 

. 191 

Cervico-Axillary  Cravat 

. 191 

Lateral  Thoracic  Bandage 

. 191 

Sternal  Triangle  . 

. 191 

Dorsal  Triangle  . 

. 192 

Thoracico-Abdominal  Bandage 

. 192 

Girdle 

. 192 

Sect.  III.  Bandages  for  the  Upper  Extremities 193 


Simple  Bandages  ....  194 

Circular  Bandages  . . . 194 

Of  a Finger  . ...  .194 

Of  the  Forearm  . . .194 

Of  the  Arm  . . . .194 

Spiral  Bandages  ....  195 

Of  a Finger  ....  195 
Of  all  the  Fingers  (Gauntlet)  . 195 

Of  the  Hand  and  Fingers  . . 196 

Of  the  Forearm  . . . 196 

Of  the  Arm  ....  196 
Of  the  Whole  Arm  . . .197 

Figure  of  8 Bandages  . . . 197 

Of  the  Thumb  and  Wrist  . 198 

Posterior,  of  the  Hand  and  Wrist  198 
Anterior,  of  the  Hand  and  Wrist  198 
Of  the  Elbow  ....  198 
Extensor,  of  the  Hand  and  Fore- 
arm .....  199 
Flexor,  of  the  Hand  and  Forearm  199 
Recurrent  Bandages  . . . 199 

Of  a Stump  of  the  Arm  and 
Forearm  ....  199 

After  Disarticulation  at  the 
Shoulder  ....  199 


Simple  Bandages — 

Handkerchief  Bandages  . . 200 

Large  Quadrilateral  Scarf  of  the 
Arm  and  Chest  . . . 200 

Oblique  Quadrilateral  Scarf  of 

the  Arm  and  Chest  . . 200 

Scarf  of  the  Arm  and  Neck  . 201 

Scarf  of  the  Hand  and  Forearm  201 

Compound  Bandages  . . . 201 

T Bandages  .....  201 
Simple  T Bandage  of  the  Hand  . 201 

Double  T Bandage  of  the  Hand  . 201 

Perforated  T Bandage  of  the 

Hand 202 

Sling  Bandages  ....  202 
Of  the  Hand  ....  202 
Anterior,  of  the  Elbow  . . 202 

Posterior,  of  the  Elbow  . . 202 

Sheath  Bandages 202 

Of  the  Fingers  ....  202 

Laced  and  Buckle  Bandages  . 202 

Laced  Bandage  of  the  Arm  . 202 

Laced  Bandage  of  the  Body 
(Strait-Jacket)  . . . 202 


CONTENTS. 


IS 


PAGE  | 

Mayor’s  Bandages  of  the  Upper  Ex- 


tremities   203 

Cravats,  Triangles,  and  Squares  . 203 

Carpo-Digito  Dorsal  Triangle  . 203 

Interdigital  Triangle  . . . 204 

Palmo-Digito-Bracliial  Triangle  . 204 

Carpo-Olecranon  Cravat  . . 204 

Carpo-Cervieal  Triangle  . . 205 


PAGE 

Mayor’s  Bandages — 

Cervico-Bracliial  Triangle  . . 205 

Triangular  Cap  of  tlie  Shoulder  . 205 

Triangular  Cap  of  Stumps  . . 205 

Rigal’s  Bandages  of  the  Upper  Ex- 
tremities .....  205 

Deltoid  Bandage  ....  205 

206 


Sect.  IV.  Bandages  for  the  Lower  Extremities 


mple  Bandages 

. 207 

Circular  Bandages 

. 207 

Of  a Toe  .... 

. 207 

Of  the  Leg 

. 207 

Spiral  Bandages  . 

. 207 

Of  a Toe  .... 

. 207 

Of  the  Leg 

. 208 

Of  the  Thigh  . 

. 208 

Of  the  Lower  Extremity  . 

. 208 

Figure  of  8 Bandages  . 

. 209 

Of  a Toe  .... 

. 209 

Of  the  Foot  and  Leg 

. 210 

Posterior,  of  the  Knee 

. 210 

Anterior,  of  the  Knee 

. 210 

Of  both  Knees  . 

. 210 

Recurrent  Bandages 

. 211 

Of  the  Leg 

. 211 

Of  the  Thigh  . 

'.  211 

Of  the  Hip 

. 211 

Invaginated  Bandages  . 

. 211 

For  Longitudinal  Wounds 

. 211 

For  Transverse  Wounds  . 

. 212 

impound  Bandages 

. 213 

T Bandages  .... 

. 213 

Single,  of  the  Foot  . 

. 213 

Double,  of  the  Foot  . 

. 213 

Sling  Bandages  . 

. 214 

Of  the  Instep  . 

. 214 

Of  the  Heel  . . 

. 214 

Of  the  Knee 

. 214 

Compound  Bandages — 

Sheath  Bandages  . . . 214 

Of  a Toe  .....  214 
Laced  Bandages  ....  214 

Of  the  Lower  Extremity  . . 214 

Mayor’s  Bandages  for  the  Lower 

Extremities  ....  215 

Cravats,  Triangles,  and  Squares  of 
the  Toes,  Foot,  Leg,  and  Thigh  . 215 

Imbricated  Squares  and  Cravats  . 215 

Tibial  Triangle  ....  215 

Popliteal  Cravat  . . . .215 

Tarso-Patellar  Cravat  . . . 215 

Compound  Metatarso-Patellar  Cra- 
vat ......  215 

Tarso-Pelvic  and  Tarso-Crural  Cra- 
vats   216 

Triangular  Cap  for  Stumps  . . 216 

Triangular  Cap  for  the  Heel . . 216 

Metatarso-Malleolar  Cravat  . . 216 

Malleolar-Phalangeal  Triangle  . 216 

Tibio-Cervical  Cravat  . . . 217 

Uniting  Cord  for  Longitudinal 
Wounds 217 

Rigal’s  Bandages  for  the  Lower  Ex- 
tremities . . . . .217 

Triangle  of  the  Trochanter  Major  217 
Bandage  for  the  Leg  . . .217 

Bandage  for  the  Foot  . . .217 


X 


CONTENTS. 


PART  II. 

MECHANICAL  BANDAGES  AND  APPARATUS. 


CHAPTER  I. 


APPARATUS  FOR  REMEDYING  LOSS  OF  PARTS. 


Deficiency  of  the  Cheeks  and  Lips 
Of  the  Palate 
Of  the  Chin 


Sect.  I.  Loss  of  Parts  of  the  Head  and  Neck 
Deficiency  of  the  Cranial  Walls  . 219 
Of  the  Integuments  . . . 219 

Of  the  Nose  ....  220 
Of  the  Eye  .....  222 

Sect.  II.  Apparatus  for  Remedying  Deficiencies  of  the  Trunk 
Deficiency  of  the  Thoracic  Walls  . 227  I Deficiency  of  the  Spinal  Canal 

Sect.  III.  Apparatus  for  Remedying  Deficiencies  of  the  Upper  Extremities 
Deficiency  of  the  Arm 

Sect.  IV.  Apparatus  for  Remedying  Deficiencies  of  the  Lower  Extremities 
Deficiency  of  the  Leg  .......... 


PAGE 

219 

223 

223 

226 

227 

228 

228 

228 

237 

237 


CHAPTER  II. 

APPARATUS  FOR  REMEDYING  LOSS  OF  FUNCTION  OF  PARTS  OF  THE  BODY. 

Sect.  I.  Apparatus  for  Remedying  Loss  of  Function  of  the  Muscles  of  the 

Head  and  Neck  ...........  252 

Loss  of  Function  of  the  Cervical  Muscles 252 


Sect.  II.  Apparatus  for  Remedying  Loss  of 

Loss  of  Function  of  the  Erector  Mus- 
cles of  the  Spine  . . . 253 

Of  the  Abdominal  Muscles — Her- 
nia ......  254 

Sect.  III.  Apparatus  for  Remedying  Loss 
Extremities  ..... 

Loss  of  Function  of  the  Muscles  of 

the  Fingers  ....  274 
Of  the  Interossei  Muscles  . .276 

Of  the  Extensor  Communis  Digi- 
torum 277 

Sect.  IV.  Apparatus  for  Remedying  the 
Lower  Extremities  .... 

Loss  of  Function  of  the  Tibialis  An- 

ticus  .....  281 

Of  the  Peronei  Muscle  . . . 281 

Of  the  Extensor  Muscles  of  the  Leg  2S2 


Function  of  Muscles  of  the  Trunk  253 
Loss  of  Function — 

Of  the  Sphincter  Ani  . . . 267 

Of  the  Uterine  Ligaments  — Pro- 
lapsus Uteri  ....  268 

of  Function  of  Parts  of  the  Upper 

274 

Loss  of  Function — 

Of  the  Extensors  of  the  Hand  . 278 

Of  the  Biceps  ....  279 
Of  the  Scapular  Muscles  . .279 

Loss  of  Function  of  Parts  of  the 

2S0 

Loss  of  Function — 

Of  the  Ligament  of  the  Knee-Joint 
— Knock-Knee  ....  2S4 

Of  the  Ligament  of  the  Hip  . 2S9 


CONTENTS 


xi 


CHAPTER  III. 


APPARATUS  FOR  REMEDYING  LOSS  OF  SYMMETRY  OF  PARTS. 

PAGE 

Sect.  I.  Apparatus  foe  Remedying  Loss  of  Symmetry  of  the  Head  and  Neck  . 289 


Deformity  of  the  Nose 
Immobility  of  tlie  Lower  Jaw  . 
Projection  of  the  Chin 
Distortion  of  the  Lips  from  Burns 


2S9 

290 

291 
291 


Deformity  of  the  Chin  and  Neck  from 
Burns  ...... 

Posterior  Curvature  of  the  Neck 
Angular  Cervical  Curvature  . 
Torticollis 


291 

292 

293 

294 


Sect.  II.  Apparatus  for  Remedying  Loss  of  Symmetry  of  the  Trunk 


297 


Lateral  Curvature  of  the  Spine  . 297  Angular  Curvature  of  the  Spine  . 310 

Posterior  Curvature  of  the  Spine  . 309  Loss  of  Symmetry  of  the  Pelvis  . 314 


Sect.  III.  Apparatus  for  Remedying  Loss  of  Symmetry  of  the  Upper  Estremi 


ties 315 

Deformity  of  the  Fingers  . . 315  Deformity  of  the  Elbow  . . . 318 

Deformity  of  the  Wrist  . . . 317 


Sect.  IV.  Apparatus  for  Remedying  Loss  of  Symmetry-  of  the  Lower  Extremi- 


ties   . 320 

Deformities  of  the  Toes  . . . 320  Bowed  or  Bandied  Legs  . . . 331 

Bunions  ......  321  Contraction  of  the  Knee-Joint  . . 333 

Deformity  of  the  Foot  and  Ankle  . 322  Contraction  of  the  Hip  . . . 336 


PART  III. 

FRACTURES : THEIR  REDUCTION,  DRESSINGS,  AND  APPARATUS. 


Classification 

Frequency 

Causes 

Symptoms 

Diagnosis 

Prognosis 


CHAPTER  I. 

GENERAL  CONSIDERATION  OF  FRACTURES. 


346 

347 

347 

348 
350 
350 


Mode  of  Repair 
Ununited  Fracture  . 

Treatment  of  Ununited  Fracture 
Compound  Fracture 
Complicated  Fracture 
General  Treatment  of  Fractures 


350 

352 

352 

354 

355 
355 


CHAPTER  II. 


FRACTURES  OF  PARTICULAR  BONES. 
Sect.  I.  Fractures  of  the  Bones  of  the  Skull  and  Face  . 


Fracture  of  the  Skull  . . .373 

Of  the  Nasal  Bones  and  Cartilages  374 
Of  the  Superior  Maxillary  Bone  . 376 


Fracture  of  the  Malar  Bone 
Of  the  Zygoma 
Of  the  Inferior  Maxillary 


. 373 
. 378 
. 378 
. 379 


Xll 


CONTEXTS 


PACE 


Sect.  II.  Fractures  of  the  Bones  of  the  Trunk  ..... 

. 386 

Fracture  of  the  Hyoid  Bone 

. 

386 

Fracture  of  the  Sternum 

. 390 

Of  the  Laryngeal  Cartilages 

387 

Of  the  Ribs 

. 391 

Of  the  Vertebrae  . 

388 

Of  the  Costal  Cartilages 

. 393 

Sect.  III.  Fractures  of  the  Bones 

OF 

the  Upper  Extremities  . 

. 393 

Fracture  of  the  Scapula  . 

393 

Fracture — 

Of  the  Clavicle  . 

397 

Of  the  Ulna 

. 431 

Of  the  Humerus  . 

409 

Of  the  Carpus 

. 4:34 

Of  the  Radius  and  Ulna 

423 

Of  the  Metacarpus 

. 434 

Of  the  Radius 

425 

Of  the  Phalanges 

. 435 

Sect.  IV.  Fractures  of  the  Bones 

OF 

the  Lower  Extremities  . 

. 435 

Fracture  of  the  Pelvic  Bones  . 

435 

Fracture  of  the  Fibula  . 

. 491 

Of  the  Femur 

437 

Of  the  Tarsal  Bones 

. 493 

Of  the  Patella 

471 

Of  the  Metatarsal  Bones 

. 494 

Of  the  Tibia  and  Fibula 

480 

Of  the  Phalanges 

. 494 

Of  the  Tibia 

490 

Rupture  of  the  Tendo-Achillis 

. 495 

PART  IV. 

DISLOCATIONS : THEIR  REDUCTION,  DRESSINGS,  AND 
APPARATUS. 

CHAPTER  I. 


SPRAINS  OR  STRAINS 496 

CHAPTER  II. 

DISLOCATIONS  IN  GENERAL. 

Nomenclature 500  j Symptoms 504 

Frequency  .....  501  Diagnosis  .....  506 

Causes 502  Prognosis 506 

Pathological  Anatomy  . . . 503  Treatment  .....  507 


CHAPTER  III. 


PARTICULAR  DISLOCATIONS. 


Sect.  I.  Dislocations  of  the  Head  and  Trunk 

511 

Dislocation  of  the  Inferior  Maxilla  . 

511 

Dislocation  of  the  Sternum 

516 

Of  the  Vertebrae  . 

514 

Of  the  Ribs  and  Costal  Cartilages 

516 

Sect.  II.  Dislocations  of  the  Upper  Extremities 

517 

Dislocation  of  the  Clavicle 

517 

Dislocation  of  the  Ulna  . 

538 

Of  the  Humerus  . 

523 

Of  the  Carpus 

539 

Of  the  Radius  and  Ulua 

532 

Of  the  Metacarpus 

541 

Of  the  Radius  . . . . 

536 

Of  the  Phalanges 

542 

CONTENTS. 


Xlll 


PACE 


Dislocation  of  tlie  Pelvic  Bones 
Of  the  Femur 
Of  the  Patella 
Of  the  Tibia 

Of  the  Semilunar  Cartilages 


Sect.  III.  Dislocations  of  the  Lower  Extremities 


547  Dislocation  of  the  Fibula 

548  Of  the  Foot 

556  Of  the  Tarsus 

557  Of  the  Metatarsus 

560  Of  the  Phalanges 


. 547 

. 560 

. 561 
. 565 
. 568 
. 569 


PART  V 


THE  MINOR  OPERATIONS  OF  SURGERY. 
CHAPTER  I. 

RUBEFACTION 570 

CHAPTER  II. 

VESICATION 573 

CHAPTER  III. 


CHAPTER  IV. 

MOXAS 585 

CHAPTER  V. 

ISSUES 586 

CHAPTER  VI. 

SETONS 589 

CHAPTER  VII. 

ACUPUNCTURE  AND  ELECTRO-PUNCTURE  . . .591 

CHAPTER  VIII. 

PUNCTURING 592 

CHAPTER  IX. 

VACCINATION 595 

CHAPTER  X. 


Actual  Cauterization 
Galvanic  Cauterization 


CAUTERIZATION 
. 577  Potential  Cauterization  . 

. 579 


. 581 


INCISIONS 


596 


XIV 


CONTEXTS 


CHAPTER  XI. 

BLOODLETTING. 

PAGE 

Sect.  I.  General  Bleeding GOO 

Venesection 600 1 Arteriotomy 606 

Sect.  II.  Local  Bleeding 608 

Cupping 608  I Leeching 610 


CHAPTER  XII. 

EXTRACTION  OF  TEETH 614 


CHAPTER  XIII. 


CATIIETERISM. 


Catlieterism  of  the  Nasal  Duct  . 619 

Of  the  Eustachian  Tube  . . 620 

Plugging  the  Posterior  Nares  . . 621 

Catlieterism  of  the  Oesophagus  . 623 

Of  the  Larynx  and  Trachea  . 624 


C II  A P T E 


Catlieterism  of  the  Large  Intestines  . 625 

Of  the  Uterus  ....  625 

Of  the  Urethra  ....  625 

Male  Urethra  ....  626 

Female  Urethra  . . . 629 


R X I Y. 


REMOVAL  OF  FOREIGN  BODIES.  ■ 


Foreign  Bodies  in  the  Skin  . . 630 

In  the  Eye  .....  632 

In  the  Ear  .....  632 

In  the  Nose  ....  635 

In  the  Pharynx  and  Oesophagus  . 635 


Foreign  Bodies — 


In  the  Larynx  and  Trachea  . 

. 637 

In  the  Urethra  and  Bladder 

. 639 

In  the  Vagina 

. 641 

In  the  Rectum 

. 641 

CHAPTER  XY. 

ON  THE  MODES  OF  ARRESTING  HEMORRHAGE  . . . 642 


CHAPTER  XYI. 

ON  THE  DRESSINGS  OF  WOUNDS. 

Incised  Wounds  ....  655  Punctured  Wounds  . . . 662 

Contused  Wounds  ....  662  Gunshot  Wounds  ....  663 

CHAPTER  XYI I. 

ANESTHESIA. 

Local  Anaesthesia  ....  666  1 General  Anaesthesia  . . . 666 


LIST  OF  ILLUSTRATIONS. 


FIG.  PAGE 

1.  Single-bladed  scalpel  . . 34 

2.  Double-bladed  scalpel  . . 34 

3.  ' 

4. 


FIG.  PAGE 

38.  Application  of  tlie  bandage  of 

Scultetus  . ...  .53 

39.  The  Maltese  cross  ...  54 

40.  Folded  compresses  ...  54 


5. 

6. 
7.' 

- Different  forms  of  the  scalpel 

35 

J 

8. 

Straight  bistoury 

35 

9. 

Curved  sharp-pointed  bistoury . 

36 

10. 

Curved  blunt-pointed  bistoury 

36 

11. 

Straight  scissors 

36 

12. 

Scissors  curved  on  the  edge 

37 

13. 

Scissors  curved  on  the  flat 

37 

14. 

Razor  for  the  pocket-case  . 

37 

15. 

Dressing-forceps 

38 

16. 

Artery  forceps  with  slide 

38 

17. 

Forceps  for  holding  pins  in  ma- 

king twisted  suture 

39 

18. 

Artery  forceps  with  arched 

points  ...... 

39 

19. 

Artery  forceps  closing  by  their 

own  spring  .... 

39 

20. 

Liston’s  forceps 

40 

21. 

Tooth-pointed  forceps 

40 

22. 

Tenaculum  .... 

40 

23. 

Lancet  ..... 

40 

24. 

Syme’s  abscess  lancet 

41 

25. 

Gum  lancet  .... 

41 

26. 

Simple  probe  .... 

41 

27. 

Gunshot  probe 

41 

28. 

Porte-meche  .... 

42 

29. 

Directors  .... 

42 

30. 

Spatula 

42 

31. 

Porte-caustic  .... 

42 

32. 

Surgical  needles 

43 

33. 

Exploring  needle 

43 

34. 

Exploring  trocar 

43 

35. 

Catheters  .... 

44 

36. 

Ivory  winder  for  suture  thread 

44 

37. 

The  many-tailed  bandage 

52 

41 . \ 

42.  \ 

43.  I 

44.  I 

45.  / 

46.  I 

47. 

48.  I 

49.  / Different  forms  of  knots  55,  56 

50. 

51. 

52.  \ 

53.  \ 

54.  \ 

55. 

56. 

57.  I 

58.  Application  of  the  many-tailed 

bandage  for  retaining  cata- 


plasms ....  81 

59.  Apparatus  for  cold  water-dress- 

ings   87 

60.  Velpeau’s  apparatus  for  irriga- 

tion .....  91 

61.  Double-tubed  catheter  . • . 94 

62.  Maisonneuve’s  irrigator  . . 95 

63.  India-rubber  cap  for  applying 

cold  water  to  the  head  . . 96 

64.  Thomson’s  bathing  apparatus  . 101 

65.  Portable  shower-bath  . . 102 

66.  Vessel  for  hip-hatli  . . . 106 

67.  Anel’s  syringe  . . . 107 

68.  Toynbee’s  syringe  and  nozzle  . 108 

69.  Toynbee’s  ear-spout  fitted  on 

the  head  ....  108 

70.  The  catheter  syringe  . . 109 


I 


xvi 


LIST  OF  ILLUSTRATION'S. 


FIS. 

PAGE  ! 

FIG. 

PAGE 

71.  Metallic  clyster-pump 

112 

112. 

Recurrent  bandage  of  the  head 

166 

72.  Hypodermic  syringe 

116 

113. 

Invaginated  bandage  for  verti- 

73.  Brindejonc’s  ventilator  . 

123 

cal  wounds  of  the  lips  . 

167 

74.  1 

l Inhalers  .... 

127 

114. 

Double  T bandage  of  the  nose  . 

168 

75.  } 

115. 

Six-tailed  bandage  of  the  head 

170 

76.  Atomizer  of  Sales-Girons 

128 

116. 

Four-tailed  bandage  of  the 

77.  Steam  atomizer 

129 

head  ..... 

170 

78.  Shield  to  protect  the  face 

129 

117. 

Four-tailed  bandage  of  the  chin 

171 

79.  Apparatus  for  applying  carbo- 

118. 

Sheath  bandage  of  the  tongue 

171 

nic  acid  to  the  uterus  . 

130 

119. 

Spica  of  the  shoulder 

179 

80.  Mode  of  making  the  single- 

120. 

Anterior  figure  of  8 of  the 

- headed  roller 

134 

shoulders  .... 

180 

81.  Bandage-roller 

134 

121. 

T bandage  of  the  groin  . 

185 

82.  Mode  of  applying  the  roller 

122. 

] 

Suspensory  bandage  of  the 

bandage  .... 

135 

123. 

J 

scrotum  .... 

186 

83.  The  square  Mayor’s  bandage  . 

138 

124. 

Elastic  suspensory  bandage  of 

84.  The  oblong  “ “ 

138 

scrotum  .... 

187 

85.  The  triangle  “ “ 

138 

125. 

Simple  bis-axillary  cravat 

188 

86.  The  cravat  “ “ 

138 

126. 

Cruro-pelvic  triangle 

190 

87.  The  cord  “ “ 

139 

127. 

Sacro-lumbar  triangle 

191 

88.  Mode  of  strapping  the  breast  . 

141 

128. 

Circular  bandage  of  a finger  . 

193 

89.  Velpeau’s  bandage  for  support- 

129. 

Spiral  of  all  the  fingers  (Gaunt- 

ing  a pendulous  abdomen 

142 

let) 

195 

90.  Dewar’s  apparatus  for  support- 

130. 

Demi-gauntlet 

196 

ing  the  suture  in  hare-lip 

143 

131. 

Spiral  bandage  of  the  whole 

91.  Carte’s  compressor  for  femoral 

arm  ..... 

197 

and  popliteal  aneurism 

146 

132. 

Carpo-olecranon  cravat  . 

204 

92.  Carte’s  compressor  for  aneurism 

133.  Spiral  bandage  of  the  lower 

of  the  upper  extremities 

146 

extremity  .... 

209 

93.  Hoey’s  clamp  .... 

146 

134. 

Posterior  figure  of  8 of  the  knee 

210 

94.  Charridre’s  compressor  . 

146 

135. 

Invaginated  bandage  for  ver- 

95. Baynton’s  plan  of  treating  ulcers 

148 

136. 

tical  wounds 

212 

96.  Bandage  scissors 

148 

137. 

Invaginated  bandage  for  trans- 

97.  Fricke’s  plan  of  treating  or- 

verse wounds 

213 

chitis  ..... 

150 

138. 

Sling  of  the  knee  . 

214 

98.  Urethral  dilators 

152 

139. 

Elastic  bandage  of  lower  extre- 

99.  Buchanan’s  compound  circular 

mity 

214 

catheter  .... 

152 

140. 

I 

100.  Sheppard’s  dilator  . 

153 

141. 

i-  Artificial  nose 

221 

101. 

1 

142. 

102. 

1 Wakely’s  dilators 

for  stric- 

143. 

Artificial  eye  . . . . 

222 

103. 

j ture 

• 

153 

144. 

Artificial  palate 

224 

104. 

1 

J 

145. 

| Hullihen’s  artificial  palate  . 

225 

105. 

Fergusson’s  mode  of 

ligating 

146. 

nsvus . 

. 

155 

147. 

Van  Petersen’s  artificial  arm  . 

229 

106.  I Erichsen’s  method  of  ligating 

107.  ) vascular  tumors 

108.  Double  canula 

109.  Ecraseurs  , . . . 

110.  Bandage  for  the  eye 

111.  Monocle 


' l Cliarriere’s  artificial  arm  . 230 

155  149.  J 

156  150.  Common  artificial  arm  . . 234 

157  151.  Artificial  arm  with  driving  hook  235 
161  152.  Diagram  showing  centre  of 

161 1 gravity  ....  238 


LIST  OF  ILLUSTRATIONS. 


XVII 


FIG. 

153. 

154. 

155. 

156. 

157. 

158. 

159. 


160. 

161. 

162. 

163. 

164. 

165. 

166. 

167. 

168. 

169. 

170. 

171. 

172. 

173. 

174. 

175. 

176. 

177. 

178. 

179. 

180. 
181. 
182, 
183. 

1S4. 

185. 

186. 

187. 

188. 

189. 

190. 


Shoe  after  amputation  at  the 
ankle  ..... 

Apparatus  for  amputation 
through  the  foot  . 

Common  socket  leg 

Artificial  leg  for  amputation  be- 
low the  knee 

Apparatus  for  extending  a con- 
tracted stump 

Wooden  pin  .... 

Diagram  showing  the  mode  of 
arranging  spiral  springs  in 
the  ankle  .... 

Bly’s  artificial  leg  . 


1 Kolbe’s  artificial  leg 


Apparatus  for  spinal  debility  . 
Single  inguinal  truss 
Salmon  and  Ody’s  single  truss. 
Salmon  and  Ody’s  double  truss 
Todd’s  truss 
Bigg’s  truss 
Hood’s  truss 
Dupre’s  truss 
Femoral  truss 
Umbilical  truss 

| Apparatus  for  prolapsus  ani. 

Mode  of  introducing  the  India- 
rubber  pessary 

I Different  forms  of  India-rub- 
j her  pessaries  . 

Hodge’s  closed  lever  pessary  . 
Gariel’s  pessary 
Uterine  supporter,  front  view  . 
Uterine  supporter,  back  view  . 
Uterine  supporter  with  mova- 
ble pad  .... 
Velpeau’s  apparatus  for  writer’s 
cramp  ..... 

| Apparatus  for  writer’s  cramp 

Apparatus  for  paralysis  of  the 
interossei  muscles. 

Apparatus  for  paralysis  of  the 
extensor  communis 
Apparatus  for  “ drop  wrist”  . 
Apparatus  for  paralysis  of  the 
biceps 


239 

240 

241 

241 

242 
242 


244 

247 

248 

254 

256 

256 

256 

257 

257 

258 

259 
360 
261 

268 


270 

270 

270 

272 

273 
273 

273 

275 

275 

276 

277 

278 

279 


FIG.  PAGE 

191.  Apparatus  for  paralysis  of  the 

tibialis  anticus  . . . 281 

192.  Supporting  frame  for  paralysis 

of  the  lower  extremities  . 282 

193.  1 Apparatus  for  paralysis  of 

194.  j the  lower  extremity  . 283 

195.  ] Apparatus  for  paralysis  of 

196.  } both  extremities  . . 284 

197.  Appearance  of  knock-knee  . 285 

198.  Knock-knee  with  outward  cur- 

vature of  the  opposite  knee  . 286 

199.  -j  287 

200.  L Apparatus  for  knock-knee  . 0g8 

201.  J 

202.  Scultetus’  lever  for  separating 

the  jaws  ....  290 

203.  Lever  for  opening  the  jaws  . 290 

204.  Bigg’s  apparatus  for  separating 

the  jaws  ....  290 

205.  Apparatus  to  prevent  deformity 

of  the  lips  ....  291 

206.  Apparatus  for  preventing  de- 

formity after  burns  . . 292 

207.  Bishop’s  apparatus  for  caries  of 

the  cervical  vertebrae  . . 294 

208.  Gutta-percha  shield  for  caries  of 

the  vertebrae  . . . 294 

209.  Bigg’s  apparatus  for  caries  of 

the  cervical  vertebrae  . . 294 

210.  Jorg’s  apparatus  for  torticollis.  295 

211.  Bonnet’s  apparatus  for  torti- 

collis .....  295 

212.  Bigg’s  apparatus  for  torticollis.  296 

213.  Apparatus  for  torticollis  . . 296 

214.  Same  applied  . . . .296 

215.  Another  form  of  apparatus  for 

torticollis  . . . .296 

216.  1 External  appearances  of  late- 

217.  J ral  curvature  . . . 298 

218.  Appearance  of  the  bones  in  late- 

ral curvature,  front  view  . 299 

219.  Appearance  of  the  bones  in  late- 

ral curvature,  back  view  . 299 

220.  Recumbent  couch  for  lateral 

curvature  ....  301 

221.  Bigg’s  couch  for  lateral  curva- 

ture .....  303 

222.  Maisonabe’s  couch  for  lateral 

curvature  ....  303 

223.  Apparatus  for  lateral  curvature  304 


2 


XV111 


LIST  OF  ILLUSTRATIONS. 


FIS. 

PACE 

FIG. 

PAGE 

224. 

Tavernier’s  apparatus  for  late- 
ral curvature 

304 

258. 

259. 

| Little’s  club-foot  apparatus  . 

327 

225. 

Tamplin’s  apparatus  for  lateral 

260. 

Modification  of  Little’s  appara- 

curvature .... 

305 

tus  

328 

226. 

Lonsdale’s  apparatus  for  lateral 

261. 

1 Appearance  of  talipes  equi- 

curvature  .... 

306 

262. 

j nus 

328 

227. 

Bigg’s  apparatus  for  lateral 

263. 

Stromeyer’s  foot-board  . . . 

329 

curvature  .... 

306 

264. 

Liston’s  apparatus  . 

329 

228. 

Brodie’s  apparatus  for  lateral 

265. 

Appearance  of  talipes  calcaneus 

331 

curvature  .... 

307 

266. 

Apparatus  for  talipes  calcaneus 

331 

229. 

Duchenne’s  apparatus  for  late- 

267. 

Shoe  for  club-foot  . 

331 

ral  curvature 

307 

268. 

Bowed  legs  .... 

332 

230. 

Kolbe’s  modification  of  Du- 

269. 

1 

chenne’s  apparatus 

308 

270. 

1 Apparatus  for  bowed  legs  » 

332 

231. 

Apparatus  for  lateral  curvature 

308 

271. 

Apparatus  for  anterior  curva- 

232. 

Apparatus  for  single  curvature 

ture  of  the  leg 

333 

of  the  spine 

309 

272. 

Apparatus  for  contraction  of  the 

233. 

Appearance  of  posterior  curva- 

knee ..... 

333 

ture  of  the  spine  . 

309 

273. 

Bonnet’s  apparatus  for  con- 

234. 

Tamplin’s  apparatus  for  poste- 

tracted knee 

334 

rior  curvature 

310 

274. 

Tamplin’s  apparatus  for  con- 

235. Appearance  of  angular  curva- 

tracted  knee 

335 

ture 

311 

275. 

Appearance  of  contracted  knee 

236. 

Tamplin’s  apparatus  for  angu- 

with displacement  of  the  tibia 

lar  curvature 

313 

backwards  .... 

335 

237. 

1 Apparatus  for  angular  curva- 

276. 

1 Bigg’s  apparatus  for  con- 

238. 

j ture  .... 

314 

277. 

j tracted  knee  . 

336 

239.  Apparatus  for  obliquity  of  the 

278. 

I Dr.  Davis’s  splints  for  eoxal- 

pelvis  ..... 

314 

279. 

} gia 

339 

240. 

1 Congenital  deformities  of  the 

280. 

Dr.  Davis’s  splints  for  coxalgia 

340 

241. 

J fingers  .... 

315 

281. 

Davis’s  splint  applied 

340 

242. 

1 Deformities  of  the  fingers  from 

282. 

Barwell’s  splint  for  coxalgia  . 

341 

243. 

j contraction  of  palmar  fascia 

316 

283. 

Aghew’s  splint  for  coxalgia 

342 

244.  Deformity  of  the  fingers  from 

284. 

Same  applied  .... 

343 

wound  of  forearm 

316 

2S5. 

| Apparatus  for  coxalgia 

343 

245. 

Deformity  of  the  fingers  from 

286. 

contraction  of  the  skin 

316 

287. 

Wire  splint  .... 

344 

246. 

Contraction  of  the  wrist  . 

317 

2S8. 

Mode  of  applying  wire  splint  . 

343 

247. 

I Apparatus  for  deformities  of 

289. 

Smith’s  apparatus  for  ununited 

248. 

j the  wrist  .... 

318 

fracture  of  the  thigh  . 

353 

249. 

Contraction  of  the  elbow  . 

318 

290. 

Smith’s  apparatus  for  ununited 

250. 

Stromeyer’s  apparatus  for  an- 

fracture of  the  leg 

353 

chylosis  of  the  elbow  . 

319, 

291. 

Air-cushions  for  splints  . 

358 

251. 

Bonnet’s  apparatus  for  anchy- 

292. 

The  same  applied  . 

35S 

losis  of  the  elbow 

319 

293. 

Seutin’s  scissors 

359 

252. 

Contraction  of  the  toe 

320 

294. 

Diagram  for  making  pasteboard 

253. 

“ Hammer  toe” 

320 

splints  for  the  thigh 

359 

254. 

Appearance  of  bunion 

321 

295. 

Diagram  for  making  pasteboard 

255. 

Apparatus  for  bunion 

321 

splints  for  the  leg 

360 

256. 

Appearance  of  talipes  varus  . 

322 

296. 

Diagram  for  making  pasteboard 

257. 

Kolbe’s  club  foot  apparatus 

326 

splints  for  the  arm 

360 

LIST  OF  ILLUSTRATIONS. 


XIX 


FIG. 

297.  Diagram  for  making  pasteboard 

splints  for  the  forearm  . 

298.  Pasteboard  splints  for  the  thigh 

299.  Pasteboard  splints  for  the  fore- 

arm ..... 

300.  Application  of  pasteboard 

splints  to  the  leg  . 

301.  Welch’s  splint  for  the  forearm  . 

302.  Seutin’s  apparatus  for  fracture 

of  the  thigh 

303.  Immovable  apparatus  for  leg  . 

304.  Specimen  showing  three  forms 

of  fracture  of  the  lower  jaw 

305.  Barton’s  bandage  for  fractured 

lower  jaw  .... 
30(3.  Gibson’s  bandage  for  fracture  of 
lower  jaw  . . . . 

307.  Hamilton’s  apparatus  for  frac- 

tured jaw  .... 

308.  j The  author’s  apparatus  for 

309.  j fractured  jaw  . 

310.  j Bean’s  apparatus  for  frac- 

311.  j turedjaw. 

312.  Fracture  of  the  acromion  process 

313.  Fracture  of  the  coracoid  process 

314.  Fracture  of  the  neck  of  the 

scapula  .... 

315.  Apparatus  for  fracture  of  the 

neck  of  the  scapula 

316.  Fracture  of  the  body  of  the 

scapula  .... 

317.  Oblique  fracture  near  the  mid- 

dle of  the  clavicle 

318.  Figure  of  8 bandage  for  frac- 

tured clavicle 

319.  Brasdor’s  apparatus  for  frac- 

tured clavicle  . 

320.  Kecherly’s  apparatus  for  frac- 

tured clavicle 

321.  Velpeau’s  apparatus  for  frac- 

tured clavicle 

322.  Lonsdale’s  apparatus  for  frac- 

tured clavicle 

323.  Fox’s  apparatus  for  fractured 

clavicle  .... 

324.  Hamilton’s  apparatus  for  frac- 

tured clavicle 

325.  | Levis’s  apparatus  for  frac- 

326.  j tured  clavicle  . 

327 . Fracture  of  the  anatomical  neck 

of  the  humerus 


FIG.  PAGE 


328: 

Fracture  of  the  surgical  neck  of 

the  humerus 

411 

329. 

Apparatus  for  fracture  of  surgi- 

cal neck  of  humerus  . 

413 

330. 

Welch’s  shoulder-splint  . 

413 

331. 

Lonsdale’s  apparatus  for  frac- 

ture of  humerus  . 

415 

332. 

Fracture  at  the  base  of  the  con- 

dyles   

416 

333. 

Physick’s  elbow  splints  . 

416 

334. 

Sir  A.  Cooper’s  splint  for  frac- 

ture of  the  humerus  . 

417 

335. 

Fergusson’s  mode  of  treating 

fracture  above  the  condyles  . 

417 

336. 

Hamilton’s  elbow  splint  . 

418 

337. 

Bond’s  elbow  splint. 

418 

338. 

Welch’s  elbow  splint 

419 

339. 

Kirkbride’s  elbow  splint  . 

419 

340. 

Rose’s  splint  .... 

420 

341. 

Day’s  splint  .... 

420 

342. 

Mayor’s  splint .... 

420 

343. 

Fracture  at  the  base  of  and  be- 

tween the  condyles 

421 

344. 

Fracture  of  the  external  con- 

dyle   

421 

345. 

Fracture  of  the  internal  con- 

dyle   

422 

346. 

Fracture  in  the  lower  third  of 

humerus  .... 

423 

347. 

Mayor’s  apparatus  for  fracture 

of  the  forearm 

425 

348. 

Fracture  of  the  shaft  of  the 

radius  ..... 

426 

349. 

Fracture  of  the  radius  near  its 

lower  end  .... 

426 

350. 

Dupuytren’s  apparatus  for  frac- 

ture of  the  radius 

427 

351. 

Nelaton’s  splint  for  fracture  of 

the  radius  .... 

427 

352. 

Bond’s  splint  for  fractured  ra- 

dius ..... 

428 

353. 

Bond’s  splint  with  strips  at- 

tached ..... 

428 

354. 

Hay’s  splint  for  fracture  of  the 

radius  ..... 

429 

355. 

Smith’s  modification  of  Bond’s 

splint,  back  view 

429 

356. 

Same,  front  view 

429 

357. 

Hamilton’s  splint  for  fracture 

of  the  radius 

430 

358. 

Hamilton’s  splint  applied 

430 

PAGE 

361 

361 

361 

362 

363 

366 

367 

379 

382 

382 

383 

385 

386 

393 

394 

395 

395 

396 

397 

399 

399 

400 

401 

405 

406 

406 

407 

409 


XX 


LIST  OF  ILLUSTRATIONS. 


ri  a. 

359.  Fracture  of  the  olecranon  pro- 

cess ..... 

360.  Sir  A.  Cooper’s  apparatus  for 

fracture  of  olecranon  . 

361.  Mayor’s  apparatus  for  fractured 

olecranon  .... 

362.  Fracture  of  the  coronoid  pro- 

cess ..... 

363.  Apparatus  for  fracture  of  the 

coronoid  process  . 

364.  Fracture  of  the  shaft  of  the  ulna 

365.  Splint  for  fracture  of  the  bones 

of  the  fingers 

366.  Fracture  of  the  pubis  and  is- 

chium . . . . . 


367. 

368. 


} 


Intra-capsular  fracture 


369.  External  characteristics  of  frac- 

ture of  neck  of  femur  . 

370.  Gibson’s  modification  of  Hage- 

dorn’s  apparatus  . 

371.  Gross’s  fracture  apparatus 

372.  Liston’s  splint 

373.  1 Walton’s  modification  of 

374.  { Liston’s  splint  . 

375.  Daniels’  fracture-bed 

376.  Same,  with  patient  upon  it 

377.  Extra-capsular  fracture  . 

378.  Miller’s  splint  for  fracture  of 

neck  of  femur 

379.  Same,  applied  .... 

380.  Sir  A.  Cooper’s  apparatus  for 

fracture  of  the  trochanter 
major  . . . . . 

381.  Fracture  at  the  base  of  the  con- 

dyles   

382.  Jenk’s  fracture-bed  . 

383.  Hewson’s  fracture-bed 

384.  Part  of  same  .... 

385.  Double-inclined  plane 

386.  Same,  applied  . . . . 

387.  Amesbury’s  double-inclined 

plane  . . . . . 

388.  Same,  applied . 

389.  Nott’s  double-inclined  plane  . 

390.  N.  R.  Smith’s  double-inclined 

plane  . . . . . 

391.  N.  R.  Smith’s  anterior  splint  . 

392.  Same,  applied  .... 

393.  Palmer’s  modification  of  the 

anterior  splint  . . < 


PAGE  ; 

431 

432 

432 

433 

434 

434 

435 

437 

438 

438 

440 

441 

442 

442 

443 

444 

445 


446 


FIG. 

394.  Physick’s  splint  for  fractured 

thigh 

395.  Boyer’s  apparatus  for  fractured 

thigh 

396.  Chapin’s  apparatus  for  frac- 

tured thigh  .... 

397.  Horner’s  apparatus  for  frac- 

tured thigh  .... 

398.  Hartshorne’s  apparatus  . 

399.  Burges’  apparatus  for  fractured 

thigh  ..... 

400.  Same,  applied  .... 

401.  Sanborn’s  apparatus  for  frac- 

tured thigh  .... 

402.  Neill’s  apparatus  for  fractured 

thigh  ..... 

403.  j Hodge’s  mode  of  making 

404.  j counter-extension 

405.  Gilbert’s  mode  of  counter-ex- 

tension .... 

406.  Gilbert’s  apparatus  applied 

407.  Dugas’  apparatus  for  fractured 

thigh  . . . . . 

408.  Dugas’  mode  of  attaching  the 

extending  hand  . 

409.  Buck’s  apparatus  for  fractured 

thigh 

410.  Mode  of  making  extension  with 

the  gaiter  .... 

411.  Mode  of  making  extension  with 


446 


447 

44S 

449 

450 

451 
454 

454 

455 

455 

456 

457 

457 

458 


cravat  ..... 

412.  Mode  of  making  extension  with 

adhesive  strips 

413.  Mode  of  applying  the  starch- 

ed apparatus  in  fractured 
thigh  . . . . . 

414  1 

r Fracture  of  the  patella 

415.  j 

416.  Sanborn’s  apparatus  for  frac- 

tured patella 

417.  Same,  applied  .... 

418.  Sir  A.  Cooper’s  apparatus  for 

fractured  patella  . 

419.  Another  apparatus  by  same  au- 

thor . 

420.  Wood’s  apparatus  for  fractured 

patella  .... 

421.  Hamilton’s  apparatus  for  frac- 

tured patella 

422.  Lonsdale’s  apparatus  for  frac- 

tured patella 


461 

461 

462 

462 

462 

463 

463 

464 

465 

466 

466 

467 

467 

467 

468 

468 
46S 

469 

469 

471 

473 

473 

473 

474 

474 

475 

476 


LIST  OF  ILLUSTRATIONS. 


XXI 


fig. 

423.  Lansdale’s  apparatus  for  frac- 

tured patella 

424.  Malgaigne’s  hooks  for  fractured 

patella  . . 

425.  ) Fractures  of  the  tibia  and 

426.  | fibula  . ' . 

427.  Fracture  bos  .... 

428.  Mode  of  suspending  the  frac- 

ture bos  .... 

429.  Another  mode  of  suspending 

fracture  bos 

430.  Starched  apparatus  for  the  leg. 

431.  Hutchinson’s  apparatus  for  frac- 

tured leg  .... 

432.  Neill’s  apparatus  for  fractured 

leg 

433.  Neill’s  apparatus  for  compound 

fracture  of  leg 

434.  Weiss’s  apparatus  for  fracture  of 

the  leg  .... 

435.  Weiss’s  apparatus  modified  by 

Fergusson  .... 

436.  Welsh’s  apparatus  for  fractured 

leg 

437.  Bauer’s  apparatus  for  fractured 

leg 

438.  Pott’s  angular  splint  for  frac- 

tured leg  .... 

439.  McIntyre’s  apparatus  for  frac- 

tured leg  .... 

440.  Malgaigne’s  apparatus  for  frac- 

tured leg 

441.  Same,  applied  .... 

442.  Gross’s  tin  splint  for  fractured  leg 

443.  Wire  splint  for  fractured  leg  . 

444.  Fracture  of  the  fibula 

445.  Dupuytren’s  splint  modified  . 

446.  Dupuytren’s  apparatus  for  frac- 

tured fibula  .... 

447.  Lonsdale’s  apparatus  for  frac- 

tured os  calcis 

448.  Apparatus  for  ruptured  tendo- 

Achillis  .... 

449.  Shoe  to  assist  walking  after  dis- 

location .... 

450.  Clove  hitch  .... 

451.  Same  applied  .... 

452.  Pulleys  and  iron  ring 

453.  Application  of  the  pulleys 

454.  Application  of  the  rope  windlass 

455.  Bloxham’s  dislocation  tourni- 

quet . . . . . 


PAGE 

456.  Double  dislocation  of  the  lower 

jaw  .....  511 

457.  Appearances  of  dislocation  of 

lower  jaw  ....  513 

458.  Dislocation  of  the  sternal  end 

of  the  clavicle  forwards  . 518 

459.  Dislocation  of  the  outer  end  of 

the  clavicle  upwards  . . 521 

460.  Apparatus  of  Mayor  for  disloca- 

tion of  the  clavicle  . . 522 

461.  Dislocation  of  the  shoulder 

downwards  ....  524 

462.  Appearance  of  dislocation  of 

shoulder  downwards  . . 525 

463.  Sir  A.  Cooper’s  method  of  se- 

curing immobility  of  scapula  526 

464.  N.  R.  Smith’s  method  of  reduc- 


ing dislocated  shoulder  . 527 

465.  Sir  A.  Cooper’s  mode  of  making 

counter-extension  with  the 
heel 527 

466.  Mode  of  reducing  dislocation  of 

shoulder  with  knee  in  axilla  528 

467.  Skey’s  iron  knob  for  axilla  . 528 

468.  Skey’s  mode  of  reducing  dislo- 

cated shoulder  . . . 52S 

469.  Mothe’s  method  of  reduction 

modified  ....  529 

470.  Subcoracoid  dislocation  . . 530 

471.  Subclavieular  dislocation  . 530 

472.  Appearance  of  subcoracoid  dis- 

location ....  531 

473.  Subspinous  dislocation  . . 531 

474.  Dislocation  of  elbow  backwards  533 

475.  Appearance  of  dislocation  of 

elbow  backwards  . . 533 

476.  Mode  of  reducing  dislocation  of 

elbow  .....  534 

477.  Incomplete  dislocation  of  the 

elbow  outwards  . . . 535 

478.  Incomplete  dislocation  of  the 

elbow  inwards  . . . 536 

479.  Dislocation  of  the  radius  for- 

wards   537 

480.  External  appearance  of  dislo- 

cation of  radius  forwards  . 538 

481.  Dislocation  of  carpus  backwards  540 

482.  Dislocation  of  carpus  forwards  540 


483.  Dislocation  of  first  phalanx  of 

thumb  backwards  . .542 

484.  Sir  A.  Cooper’s  mode  of  re- 

ducing dislocated  thumb  . 544 


PAGE 

476 

477 

480 

482 

483 

483 

484 

4S4 

485 

485 

486 

487 

487 

487 

488 

489 

490 

490 

491 

491 

492 

493 

493 

493 

495 

499 

507 

507 

508 

508 

509 

509 


xxii  LIST  OF  ILLUSTRATIONS. 


FIG. 

PAGE 

FIG. 

PAGE 

485. 

Levis’s  instrument  for  dislocated 

510. 

1 

Dislocation  of  the  foot  for- 

phalanges .... 

544 

511. 

J 

wards  .... 

561 

486. 

Same,  applied 

544 

512. 

\ 

Dislocation  of  the  foot  back- 

487. 

“Indian  puzzle,”  employed  for 

513. 

J 

wards  .... 

562 

the  reduction  of  dislocation 

514. 

Dislocation  of  the  foot  inwards 

563 

of  the  phalanges  . 

545 

515. 

Reduction  of  dislocation  of  the 

488. 

Dislocation  of  the  first  phalanx 

foot  with  pulleys 

564 

of  the  thumb  forwards 

546 

516. 

Dislocation  of  the  foot  outwards 

564 

489. 

Reduction  of  dislocation  of  the 

517. 

Dislocation  of  the  astragalus 

phalanx  backwards  by  ex- 

outwards .... 

566 

tension  .... 

546 

518. 

Compound  dislocation  of  the 

490. 

Dislocation  of  second  phalanx 

astragalus  inwards 

567 

of  finger  backwards 

547 

519. 

Corrigan’s  button  cautery 

572 

491. 

Iliac  dislocation,  anatomical  re- 

520. 

Different  forms  of  the  cautery  . 

578 

lation  ..... 

548 

521. 

1 

492. 

Iliac  dislocation,  external  ap- 

522. 

> Galvanic  cauteries 

580 

pearance  .... 

548 

523. 

493. 

Diagram  showing  application  of 

524. 

Marshall’s  galvanic  seton 

581 

the  flexion  method  in  the  re- 

525. 

Bunsen’s  battery  with  cauteries 

duction  of  dislocated  hip 

550 

attached  .... 

581 

494. 

Method  of  reducing  dislocated 

526. 

' 

Maisonneuve’s  plan  of  cau- 

hip  with  pulleys  . 

550 

527. 

y . 

tenzation  .... 

584 

495. 

Sciatic  dislocation,  anatomical 

528. 

relation  .... 

551 

529. 

Porte-moxa  .... 

585 

496. 

Sciatic  dislocation,  external  ap- 

530. 

Seton-needle  armed 

589 

pearance  .... 

551 

531. 

Mode  of  introducing  the  seton 

590 

497. 

Method  of  reducing  sciatic  dis- 

532. 

] 

location  with  pulleys  . 

552 

533. 

y Acupuncture  needles  . 

591 

498. 

Thyroid  dislocation,  anatomical 

534. 

. 

relation  .... 

553 

535. 

Manner  of  holding  the  bistoury 

499. 

Thyroid  dislocation,  external 

in  opening  abscesses 

593 

appearance  .... 

553 

536. 

Manner  of  holding  the  bistoury 

500. 

Mode  of  reducing  thyroid  dis- 

in opening  deep-seated  ab- 

location with  pulleys  . 

554 

scesses  .... 

593 

501. 

Pubic  dislocation,  anatomical 

537. 

Mode  of  holding  Syme’s  ab- 

relation  .... 

555 

scess-lancet .... 

594 

502. 

Pubic  dislocation,  external  ap- 

538. 

The  trocar  .... 

594 

pearance  .... 

555 

539. 

Scalpel  held  as  a pen 

597 

503. 

Mode  of  reducing  pubic  dislo- 

540. 

Scalpel  held  as  a violin -bow  . 

597 

cation  with  pulleys 

555 

541. 

Bistoury  held  as  a carving-knife 

598 

504. 

Dislocation  of  the  patella  out- 

542. 

Manner  of  using  the  bistoury 

wards  ..... 

556 

with  the  finger  as  a director 

598 

505. 

Dislocation  of  the  patella  in- 

543. 

' 

wards  ..... 

557 

544. 

506. 

Dislocation  of  the  head  of  the 

545. 

tibia  backwards  . 

55S 

546. 

• Different  forms  of  incision  . 

599 

507. 

Dislocation  of  the  head  of  the 

547. 

tibia  forwards 

559 

548. 

508. 

Incomplete  dislocation  of  tibia 

549. 

outwards  .... 

559 

550. 

509. 

Incomplete  dislocation  of  tibia 

551. 

Knife  for  subcutaneous  inci- 

inwards  .... 

559 

sions  ..... 

600 

LIST  OF  ILLUSTRATIONS. 


XXU1 


FIG. 

PAGE 

Fra. 

PAGE 

rci) 

f Anatomical  relation  of  the 

586. 

Catheter  showing  the  proper 

-<  veins  in  the  bend  of  the 

curve  ..... 

626 

553. 

(-  elbow  .... 

601 

5S7. 

Mode  of  introducing  the  cathe- 

554. 

Mode  of  holding  the  thumb- 

ter  ..... 

627 

lancet  in  bleeding 

602 

588. 

Hypertrophy  of  the  middle 

555. 

Spring-lancet  .... 

603 

lobe  of  the  prostate  gland 

628 

556. 

Mode  of  arresting  hemorrhage 

589. 

Velpeau’s  method  of  fastening 

from  the  brachial  artery 

604 

a catheter  .... 

628 

557. 

Bleeding  at  the  jugular  vein  . 

605 

590. 

Method  of  holding  the  female 

558. 

Mode  of  dividing  the  temporal 

catheter  .... 

629 

artery  in  auteriotomy  . 

607 

591. 

Retentive  bandage  for  the  fe- 

559. 

Bandage  and  compress  applied 

male  catheter 

629 

after  arteriotomy 

607 

592. 

Eriehsen’s  mode  of  removing 

560. 

Mode  of  attaching  an  air-pump 

foreign  bodies  from  the  skin 

631 

to  the  cupping-glass  . 

609 

593. 

Toynbee’s  ear  speculum  . 

633 

561. 

Cupping-glass  with  India-rub- 

594. 

"Wilde’s  ear  speculum 

633 

ber  ball  attached . 

609 

595. 

Otoscope  ..... 

633 

562. 

Scarificator  .... 

609 

596. 

Instrument  for  removing  for- 

563. 

Kolbe’s  mechanical  leech 

613 

eign  bodies  from  the  ear 

633 

564. 

Forceps  for  the  upper  incisors 

597. 

Toynbee’s  forceps  for  removing 

and  cnspidati 

614 

foreign  bodies  from  the  mea- 

565. 

Forceps  for  the  lower  incisors 

tus  ..... 

634 

and  cuspidati 

615 

598. 

Hewson’s  forceps 

634 

566. 

Forceps  for  the  bicuspidati 

615 

599. 

Corse’s  instrument  for  remov- 

567. 

Forceps  for  the  lower  molars  . 

615 

ing  foreign  bodies  from  the 

568. 

Forceps  for  the  right  upper  mo- 

ear  

634 

lars  ..... 

616 

600. 

569. 

Forceps  for  the  left  upper  molars 

616 

601. 

v Bond’s  gullet  forceps  . 

635 

570.  Forceps  for  the  last  molars 

616 

602. 

Mode  of  introducing  the  forceps 

571.  Forceps  in  extracting  lower  in- 

into  the  gullet 

636 

cisor  ..... 

617 

603. 

Bond’s  gullet  hook  . 

636 

572. 

Forceps  in  extracting  upper 

604. 

Instrument  for  removing  nee- 

molars .... 

617 

dles  from  the  gullet 

637 

573. 

Mode  of  using  the  key  in  ex- 

605. 

Gross’s  instrument  for  removing 

tracting  teeth 

618 

foreign  bodies  from  the  oeso- 

574. 

Diagram  showing  the  anatomi- 

phagus .... 

637 

cal  relation  of  the  canaliculi 

606. 

Weiss’s  urethral  dilator  . 

639 

with  the  nasal-duct 

619 

607. 

Urethra  forceps 

639 

575. 

Anel’s  probe  .... 

619 

608. 

Weiss’s  forceps 

640 

576. 

■ Styles  for  dilating  nasal- 

609. 

Instrument  for  removing  for- 

577. 

« duct 

620 

eign  bodies  from  the  urethra 

640 

578. 

J 

610. 

Double-bladed  urethra  forceps 

640 

579. 

Morgan’s  probe 

620 

611. 

Urethra  forceps 

640 

580. 

Flexible  tube  and  the  Eusta- 

612. 

Scoop  for  removing  foreign 

chian  catheter  into  which  it  fits 

620 

bodies  from  the  rectum 

641 

581. 

Belloc’s  sound  .... 

621 

613. 

Mode  of  compressing  the  bra- 

582. 

Mode  of  plugging  the  nares 

622 

chial  artery  .... 

645 

583. 

Stricture  of  the  gullet 

623 

614. 

Mode  of  compressing  the  femo- 

584. "Sponge  probang 

624 

ral  artery  .... 

646 

585. 

Diagram  showing  the  sizes  of 

615. 

Mode  of  compressing  the  popli- 

catheter .... 

626 

teal  artery  .... 

646 

XXIV 


LIST  OF  ILLUSTRATIONS. 


FIG. 

PAGE 

FIG. 

PAGE 

616. 

Spanish  windlass 

647 

628. 

1 Mode  of  introducing  the  acu- 

617. 

Field  tourniquet 

647 

629. 

J pressure  needle 

653 

618. 

Petit’s  tourniquet  . 

648 

630. 

Tortion  of  an  artery 

655 

619. 

Tourniquet  applied  to  tlie  bra- 

631. 

The  interrupted  suture  . 

659 

chial  artery  .... 

648 

632. 

The  continuous  suture 

659 

620. 

Tourniquet  applied  to  the  femo- 

633. 

l Needles  for  twisted  suture  . 

659 

ral  artery  .... 

648 

634. 

J 

621. 

Dupuytren’s  compressor . 

649 

635. 

Twisted,  suture 

660 

622. 

Gross’s  arterial  compressor 

649 

636. 

Pin-pliers  . . . . 

660 

623. 

Ligature  of  an  artery 

650 

637. 

India-rubber  suture 

660 

624. 

Mode  of  tying  a ligature 

651 

638. 

Quilled  suture 

660 

625. 

The  sailor’s  knot 

651 

639. 

The  serrefine  .... 

661 

626. 

Tenaculum  needle,  armed  with 

640. 

Bullet  forceps  .... 

664 

a ligature  .... 

652 

641. 

Kolbe’s  bullet  forceps 

664 

627. 

Physick’s  artery  forceps  . 

652 

642. 

Bullet  extractors 

665 

ELEMENTARY  OPERATIONS 


IN 

SURGERY. 


PART  I. 

OF  THE  “APPARATUS  OF  DRESSING.” 

By  the  term  “ Apparatus  of  Dressing,”  or,  more  simply,  Apparatus, 
are  meant,  technically,  all  the  portions  or  pieces  of  a surgical  dressing, 
with  the  instruments  used  in  their  application.  For  convenience  of 
description  we  shall  divide  the  apparatus  into  four  parts : — 

1st.  The  instruments  of  dressing. 

2d.  The  first  pieces  of  dressing,  or  those  applications  which  are 
placed  in  direct  contact  with  the  skin,  as  lint  and  adhesive  plaster. 

3d.  The  second  pieces  of  dressing,  or  bandages  properly  so  called, 
as  the  roller  and  its  modifications,  and  intended  to  be  placed  over  the 
first  pieces  to  retain  them  in  the  situation  they  are  designed  to  occupy. 

4th.  Those  mechanical  contrivances  variously  called  apparatus, 
mechanisms,  or  machines  employed  in  the  treatment  of  deformities, 
fractures,  and  dislocations. 

Surgical  dressings  may  be  defined  to  be  the  proper  and  regular 
application  of  mechanical  means,  or  topical  remedies,  to  parts  diseased 
or  injured,  from  internal  or  external  causes,  with  a view  of  restoring 
them  to  health. 

It  requires  on  the  part  of  the  surgeon  ingenuity  and  dexterity  only 
to  be  acquired  by  long  practice  to  obtain  all  the  advantages  procura- 
ble from  the  proper  and  methodical  application  of  surgical  dressings, 
bandages,  and  apparatus. 


CHAPTEE  I. 

OF  THE  INSTRUMENTS  OF  DRESSING. 

In  the  daily  routine  of  duty,  in  dressing  and  performing  elemen- 
tary operations,  experience  has  taught  us  the  utility  of  certain  instru- 
ments which,  for  convenience,  security,  and  portability,  are  usually 
arranged  upon  an  oblong  piece  of  leather  under  little  loops,  and,  fold- 
ing up  in  a compact  form  or  packet,  is  called  the  pocket-case. 

3 


34 


OF  THE  INSTRUMENTS  OF  DRESSING. 


A considerable  amount  of  taste  and  judgment  as  to  the  number  and 
kind  of  instruments,  with  which  he  fills  his  case,  may  be  displayed  by 
the  surgeon,  but  we  intend  to  limit  our  descriptions  to  those  onlv 
which  are  of  real  practical  use. 

There  are  two  kinds  of  knives,  scalpels  and  bistouries,  differing  from 
each  other  simply  in  the  width  of  the  blade,  the  former  being  more 
or  less  broad,  and  the  latter  narrow. 

Scalpels  vary  among  themselves,  not  only  as  regards  the  size  of 
the  blade,  but  also  in  the  degree  of  convexity  of  its  cutting  edge, 
according  to  the  individual  views,  convenience,  or  taste  of  the  opera- 
tors. The  blades  are  articulated  with  handles  of  horn,  ivory,  or  tor- 
toise shell,  either  fixedly,  as  in  the  ordinary  operating  scalpel,  or 
movably.  In  the  latter  case,  the  handle  consists  of  two  lateral  pieces 
riveted  at  one  end  with  the  heel  of  the  blade,  and  at  the  other  with  a 
small  intervening  fragment  of  ivory  to  separate  them  at  a convenient 
distance  for  the  reception  of  the  blade.  By  this  arrangement  the 
cutting  edge  (Fig.  1)  is  protected,  and  the  lateral  pieces  being  open 


Fig.  1. 


Single-bladed  scalpel. 


upon  both  sides,  front  and  back,  the  instrument  may  be  thoroughly 
cleansed  from  blood  or  moisture  which,  if  permitted  to  remain,  would 
rust  the  blade  and  render  it  unfit  for  use.  Upon  the  handle,  near  the 
rivet,  there  is  an  oblong  slit  with  a little  pin  playing  in  it.  to  slide 
behind  the  apex  of  the  heel  to  maintain  the  blade  open  when  the 
knife  is  in  use,  so  as  not  to  risk  inj  uring  the  operator’s  hand,  or  the 
patient,  by  any  sudden  and  unexpected  closure,  or  to  permit  the  blade 
opening  when  it  has  been  shut  and  the  instrument  placed  in  the  case. 
It  is  the  custom  now,  in  order  to  diminish  the  number  of  instruments 
in  the  pocket-case , to  rivet  two  blades,  instead  of  one,  to  the  handle,  as 
seen  in  Fig.  2. 

Fig.  2. 


For  the  purpose  of  operating,  those  scalpels  are  the  best  with  the 
blade  and  handle  immovably  articulated  and  the  lateral  surfaces  of 
the  latter  somewhat  roughened,  which  enables  the  surgeon  to  seize 


BISTOURIES. 


35 


them  firmly,  so  that  they  are  not  apt  to  slip  from  his  hand  when 
covered  with  blood.  The  common  forms  of  scalpels  now  in  use  are 
seen  in  the  annexed  sketch.  Fig.  6 shows  one  with  a moderately 
convex  edge,  the  point  at  the  summit  of  its  axis,  and  the  back  slightly 


Fig.  3.  Fig.  4.  Fig.  5.  Fig.  6.  Fig.  7. 


Different  forms  of  the  scalpel. 


convex  at  the  anterior  part  of  the  blade,  with  two  narrow  lateral 
facets  joining  behind  and  forming  a cutting  edge,  which  will  be  found, 
generally,  the  most  convenient  and  useful  in  making  incisions  and 
dissections. 

The  pocket-case  is  occasionally  furnished  with  three  or  four  blades 
of  different  sizes  fitted  to  one  handle,  in  such  a manner  that  they  may 
be  articulated  or  disarticulated  at  pleasure,  and  when  not  in  use  they 
are  secured,  under  loops,  to  a small  piece  of  leather  folding  upon 
itself,  and  kept  in  one  of  the  compartments  of  the  case. 

Bistouries. — There  are  four  forms  of  the  bistoury  in  constant  use, 
in  the  daily  routine  of  practice : 1st.  A straight  (Fig.  8)  and  sharp- 


Fig.  8. 


Straight  bistoury. 


pointed  instrument  which  is  exceedingly  light,  and  well  adapted  for 
making  neat  incisions,  and  is  preferred  by  French  surgeons  for  ope- 
rating. 2d.  The  straight  and  blunt-pointed  bistoury  is  employed 
sometimes,  in  the  neighborhood  of  important  arteries,  nerves,  and 
other  organs,  to  avoid  puncturing  them  when  the  incisions  are  carried 
to  a considerable  depth,  and  where,  perhaps,  the  point  of  the  finger 
alone  guides  the  knife.  3d.  The  curved  sharp-pointed  bistoury  (Fig. 
9)  is  in  more  continual  demand  by  the  surgeon  for  incising  and  punc- 


36 


OF  THE  INSTRUMENTS  OF  DRESSING. 


turing  than  any  of  the  varieties  of  this  instrument.  It  is  made  to  act 
in  most  cases  from  within  outwards,  as  in  opening  abscesses  or  other 


Fig.  9. 


Curved  sharp-pointed  bistoury. 


morbid  fluid  collections,  slitting  up  sinuses  and  fistulas,  and  in  in- 
cising the  tissues  upon  a director.  4th.  The  last  form  of  the  bistoury 
(Fig.  10)  is  curved  and  blunt-pointed.  Its  utility  is  restricted  to  a 


Fig.  10. 


Curved  blunt-pointed  bistoury. 


small  number  of  cases,  such  as  relieving  deep-seated  strictures  in 
strangulated  hernia,  incising  subcutaneous  bridles,  dividing  tendons, 
and  laying  open  the  skin  upon  the  grooved  director. 

Scissors. — Although  not  absolutely  necessary,  three  pairs  of  scis- 
sors of  different  forms  will  render  the  pocket-case  more  complete  and 
convenient;  they  are  the  straight  (Fig.  11),  the  angular  (Fig.  12),  and 
those  curved  upon  the  flat  (Fig.  13). 

These  instruments  should  be  sharp,  and  their  blades  so  riveted 
together  as  to  enable  the  operator  to  bring  their  edges  in  contact 
perpendicularly  that  they  may  not  catch,  nor  yet  separate  so  far  as  to 
allow  the  tissues  or  linen  to  slip  between  them,  and  be  crushed,  instead 


Fig.  ll. 


of  being  neatly  divided.  The  rings  should  be  out  of  the  axis  of  the 
stems  and  permit  these  to  lie  in  close  contact. 

Charriere,  of  Paris,  has  modified  the  manner  of  articulating  the 
blades  in  the  following  manner : one  of  them  is  provided  with  a tenon 
upon  its  inner  side,  and  the  other  with  an  elliptical  slit,  or  perfora- 
tion, which  receives  the  tenon  in  such  a way  as  to  preclude  the  possi- 
bility of  their  separation,  however  wide  they  may  be  opened.  The 
advantage  claimed  for  this  plan  is  that  the  blades  can  be  disarticulated 
at  will  and  thoroughly  cleansed ; the  old  arrangement  not  permitting 
this,  the  blood  or  fluid  of  any  kind  with  which  the  scissors  may  have 
been  brought  in  contact  collects  about  the  rivet  and  rusts  it,  and  thus 


SCISSORS — RAZOR.  37 

prevents  their  free  play ; oi’,  worse  yet.  loosens  the  blades  to  such  an 
extent  that  their  edges  bruise  the  objects  brought  between  them. 
Nevertheless,  the  tenon  wears  by  constant  use  and  permits  the  blades 


Fig.  12. 


to  separate,  so  that  the  last  objection  holds  also  against  the  new 
arrangement. 

The  straight  scissors  are  generally  used  for  cutting  dressings  and 
bandages ; those  curved  on  the  flat  for  removing  any  excrescences, 
as  warts,  &c.,  and  for  operating  in  cavities  where  straight  blades  could 
not  act  to  advantage,  if  at  all.  The  angular  scissors,  or  those  curved 
upon  the  edge,  will  be  found  convenient  in  dividing  the  tissues  raised 

Fig.  13. 


Scissors  curved  on  the  flat. 

upon  a director;  laying  open  fistulous  canals — the  angularity  per- 
mitting one  of  their  blades  to  be  slid  under  the  skin  in  a parallel 
direction.  It  is  the  proper  instrument  to  use,  also,  when  a roller 
bandage  is  to  be  removed. 

In  using  the  scissors  they  are,  commonly,  held  by  the  thumb  and 
the  middle  or  third  finger  being  placed  in  their  rings,  while  the  index 
finger  is  extended  along  the  side  for  the  purpose  of  steadying  them  ; 
however,  convenience  and  habit  are  the  best  guides  in  this  matter. 

Razor. — It  is  always  desirable  to  have  a razor  in  the  pocket-case, 
to  remove  the  hair  from  those  parts  upon  which  dressings  are  to  be 
applied  or  an  operation  performed ; it  is  an  inelegant  habit  to  use  the 


Fig.  14. 


Razor  for  the  pocket-case. 


operating  scalpels  and  bistouries  for  this  purpose,  to  say  nothing  of 
the  damage  it  does  their  edges.  Fatty  substances  applied  to  hairy 


38 


OF  THE  INSTRUMENTS  OF  DRESSING. 


surfaces  glue  the  hairs  together  in  hard  and  irritating  knots,  or  cause 
them  to  adhere  to  the  dressings,  rendering  their  removal  difficult  and 
painful. 

In  manipulating  with  the  razor  apply  its  blade  nearly  flat  to  the 
part,  and  then  by  a quick  sawing  motion  cut  the  hair  from  above 
downwards. 

Forceps. — There  are  two  pairs  of  forceps  in  the  pocket-case:  the 
dressing  or  ring  forceps  and  the  artery  forceps. 

The  dressing-forceps  are  commonly  constructed  like  the  scissors, 
except  that  their  anterior  branches  are  made  in  the  form  of  stems 
which  are  broad  at  their  extremities  and  grooved  transversely  in  five 


Fig.  15. 


or  six  little  eminences  upon  their  inner  surface,  forming  jaws  which, 
when  closed,  interlock,  so  that  a firm  hold  may  be  had  upon  anything 
seized  by  them. 

A still  better  form  of  this  instrument  (Fig.  15)  is  that  modelled  after 
the  French  polypus  forceps,  the  branches  of  which  cross  each  other  in 
such  a manner  that  the  stems  occupy  less  room,  opened,  than  when  they 
are  closed.  When  the  dressing-forceps  are  employed  they  may  be 
held  in  the  same  way  as  the  scissors. 

The  artery  forceps  (Fig.  16)  resemble  those  used  in  dissection,  in 
having  their  blades  solidly  riveted  to  a small  piece  of  intervening 
steel  at  one  end,  and  separating  at  the  other  by  their  own  spring. 
They  are  held  between  the  thumb  and  the  index  and  middle  fingers; 
and  should  be  so  constructed  as  to  be  easily  closed  by  gentle  pressure, 
for  any  unusual  stiffness  of  the  spring  tires  the  fingers.  The  outer 


Fig.  16. 


surfaces  of  the  middle  sections  of  the  blades  are  file-cut,  to  prevent 
the  instrument  slipping  from  the  fingers  when  bloody.  The  inner 
borders  of  their  points  are  grooved  transversely  to  enable  them  to 
retain  any  object  seized ; and  crossing  these  perpendicularly  is  another 
groove  terminating  above  in  a little  round  pit,  to  receive  a pin  or  a 
needle.  To  secure  the  blades  fixedly  upon  the  object  between  their 
jaws,  a catch-slide  or  spring  is  fitted  to  them. 


FORCEPS. 


39 


For  holding  pins  or  needles  in  making  the  twisted  suture  the  forceps 
seen  in  Fig.  17  are  better  adapted  than  the  preceding;  the  slide 


Fig.  17. 


Forceps  for  holding  pins  in  making  twisted  suture. 


presses  directly  upon  the  points  of  the  instrument,  and  must,  there- 
fore, necessarily  cause  these  to  grasp  the  pin  more  firmly. 

Forceps  are  designed  to  replace  the  fingers  in  situations  where 
these  could  not  be  used  to  advantage,  or  where  the  objects  are  too 
small  to  be  grasped  by  them.  The  ring  forceps  are  used  to  remove 
soiled  dressings  from  wounds,  and  loose  fragments  of  bone  or  other 
foreign  bodies  from  the  tissues. 

The  artery  forceps  have  finer  points,  and  are  suitable  for  seizing 
small  objects,  such  as  pins,  threads,  &c.,  and  the  mouths  of  bleeding 
vessels  for  ligation  and  torsion,  though  in  the  latter  case  the  points  of 
the  instrument  are  liable  to  be  caught  in  the  loop  of  the  thread  when 
the  knot  is  being  tied  upon  the  artery ; to  obviate  this  annoyance  the 
forceps  seen  in  Fig.  18  are  used.  They  have  broad  and  arched  jaws, 


Fig.  18. 


which  throw  the  loop  from  their  sloping  sides  upon  the  artery  when 
the  knot  is  drawn  tight.  To  confer  additional  lightness,  the  points  of 
the  forceps  are  also  fenestrated. 

Another  form  of  artery  forceps  is  seen  in  Fig.  19 ; they  are  of  the 


Fig.  19. 


same  shape  as  the  former,  but  their  blades  cross  each  other  in  such  a 
manner  as  to  close  by  their  own  spring. 

Liston’s  bull-dog  forceps  have  their  points  armed  with  little  teeth, 
and  the  blades  are  held  together  by  a spring,  as  seen  in  Fig.  20. 

Velpeau  ( Operative  Surgery,  vol.  i.  p.  92)  advises  the  addition  to  the 
pocket-case  of  a pair  of  forceps  armed  at  their  extremities  with  three 


40 


OF  THE  INSTRUMENTS  OF  DRESSING. 


Fig.  20. 


Tooth-pointed  forceps. 


small  mouse-like  teeth,  two  upon  one  side  and  one  upon  the  other, 
which  can  in  some  cases  be  used  with  extreme  advantage  (Fig.  21). 

Tenaculum. — The  tenaculum  is  a delicate  sharp-pointed  hook  with 
its  heel  fixed  in  a handle  like  a bistoury.  It  is  used  to  draw  out  the 


Fig.  22. 


Tenaculum. 


mouths  of  bleeding  vessels  to  be  ligated,  and  sometimes  for  the  torsion 
of  small  arteries. 

Lancets. — The  thumb-lancet  (Fig.  23)  is  a short-pointed  blade  with 

a cutting  edge  upon  both  sides,  for 


Fig.  23. 


a third  of  its  length.  Its  heel  is 
articulated  with  a handle,  the  late- 
ral halves  of  which,  being  free  at 
their  remote  ends,  are  movable 
upon  each  other,  permitting  the 
instrument  to  be  easily  cleansed. 
The  cutting-point  varies  in  length ; 
and,  from  its  shape,  is  sometimes 
called  the  oat-eared,  the  barley- 
eared, and  the  serpent-tongued 
lancet.  Either  of  these  is  used 
according  to  the  greater  or  less 
depth  at  which  the  vein,  or  collec- 
tion of  matter  can  be  reached. 

Some  persons  have  deemed  a 
special  instrument  necessary  for 
opening  abscesses ; it  is  constructed 
like  the  ordinary  thumb-lancet,  but  with  a broader  and  longer  blade, 
and  an  elongated  and  slightly  curved  point  (Fig.  24). 

Special  vaccinating  lancets  are  sometimes  employed;  they  have 
blades  quite  narrow,  and  a groove  a quarter  of  an  inch  long  in  their 


Thumb-lancet. 


PROBES. — THE  PORTE- MECHE. 


41 


Fig.  24. 


axis,  and  terminating  at  the  point  to  permit  the  ready  flow  of  the 
vaccine  matter  beneath  the  epidermis. 

The  gum-lancet  consists  of  a narrow  stem  with  a curved  cutting 


Fig.  25. 


Gum-lancet. 


point,  and  its  heel  riveted  to  a handle  in  the  manner  of  the  tenacu- 
lum. Its  name  sufficiently  indicates  its  use. 

Probes. — Probes  are  delicate  metallic  stems  for  exploration,  and 
should  be  made  of  silver,  in  order  to  be  sufficiently  tough  and  flexible 
to  assume  any  shape  required  by  the  devious  courses  of  wounds  and 
fistulas.  They  are  of  three  kinds — the  simple,  the  eyed,  and  the 
grooved  probe ; all  of  them  have  at  one  end  a little  globular  enlarge- 
ment. The  simple  probe  has  the  other  end  terminating  in  a sharp 
point  of  a prismatic  shape ; the  second  (Fig.  26)  has  an  eye,  which 

Fig.  26. 


Simple  probe. 

serves  the  purpose  of  inserting  a seton,  or  passing  a ligature;  and  the 
grooved  probe,  as  its  name  indicates,  has  a narrow  canal  coursing  half 
its  length,  and  is  employed  to  direct  the  point  of  a knife  in  laying 
open  very  contracted  sinuses. 

The  military  surgeon  sometimes  avails  himself  of  a cylindrical  me- 
tallic stem,  usually  in  two  or  three  sections,  and  called  the  gunshot 

Fig.  27. 

o — - <e 

Gunshot  prohe. 

probe  (Fig.  27),  for  exploring  at  greater  depths  than  any  ordinary 
probe  would  permit  him  to  go. 

The  Porte-meche  (Fig.  28).— One  may  often  conveniently  avail 
himself  of  the  assistance  of  a little  instrument  called  the  porte-meche 
for  inserting  threads  or  tents  into  narrow  wounds,  fistulas,  or  other 
cavities.  It  is  simply  a stem  of  silver,  with  one  of  its  extremities 
notched  or  forked  to  hold  the  threads,  and  the  other  terminating  in  a 


42 


OF  THE  INSTRUMENTS  OF  DRESSING. 


Fig.  28. 

■ - 

Porte-meclie. 

little  button.  To  use  it,  place  the  central  part  of  the  meche  upon  the 
fork,  and  draw  its  ends  along  the  sides  of  the  stem  towards  the  button, 
which  rests  against  the  palm  of  the  hand,  while  the  thumb,  index  and 
middle  fingers  support  the  stem  and  the  meche  at  the  same  instant. 

The  Director.- — This  is  a grooved  steel  stem  four  or  five  inches 
long,  terminating  at  one  end  in  a cul-de-sac,  and  at  the  other  in  a 
broad  plate  fissured  at  its  centre,  and  by  which  it  is  supported  with 
the  thumb  and  index-finger.  The  split  plate  may  be  employed  in 
steadying  contracted  bridles  while  they  are  being  divided,  as  the 


Fig.  29. 


Directors. 


frasnum  of  the  tongue.  The  groove  in  the  stem  acts  the  part  of  a 
conductor  for  the  point  of  a knife  or  scissors  in  slitting  up  sinuses. 
The  point  of  the  director  is  an  excellent  means  for  dividing  or  tearing 
through  the  cellular  tissue  over  an  artery,  for  the  purpose  of  ligating  it. 

The  Spatula. — The  common  spatula  is  a narrow,  thin  steel  plate, 
four  or  five  inches  long,  used  for  spreading  plasters  and  cloths  with 
cerate,  and  for  scraping  fatty  or  other  offending  matter  from  the  skin. 
The  French  spatula  (Fig.  30)  is  a much  more  useful  instrument,  and, 


Fig.  30. 


Spatula. 


like  the  preceding,  is  made  of  steel;  one-half  of  its  length  is  expanded 
into  an  elliptical  plate,  convex  on  one  side,  and  with  a crest  running 
along  the  middle  of  the  other,  bounded  laterally  by  two  concave  sur- 
faces ; the  other  end  forms  a stem  with  a transversely  grooved  point, 
and  makes  a good  elevator ; the  broad  portion  answers  the  same  pur- 
poses as  the  former  spatula. 


Fig.  31. 


Porte-caustic. 


The  Porte-caustic  (Fig.  31)  is  a simple  hollow  cylinder  or  tube  of 
silver,  vulcanized  India-rubber,  or  ebony,  to  receive  a stick  of  nitrate 
of  silver,  which  serves  a great  variety  of  surgical  purposes,  as  the 
curing  of  chronic  inflammations,  repressing  exuberant  granulations, 


NEEDLES — ARTERY  NEEDLE. 


43 


and  stimulating  indolent  ulcers.  The  porte-caustic,  as  it  is  usually 
furnished  by  the  manufacturer,  is  in  three  parts,  fitting  together;  one 
end  of  the  middle  section  supports  a cleft  tube  of  platinum,  with  a 
ring  sliding  upon  it  to  hold  the  caustic,  while  the  other  contains  a 
reserve  supply  of  this  article,  preserved  from  the  air  by 
the  cap  or  third  section  shutting  it  up  in  the  tube.  The  FlS-  34- 
'caustic  pencil  should  be  carefully  cleansed  of  all  moisture 
before  inclosing  it  in  the  case.  Besides  the  nitrate  of  sil- 
ver, it  will  be  found  advantageous  to  have  a crystal  of  the 
sulphate  of  copper,  trimmed  to  a blunt  point,  in  one  of 
the  compartments  of  the  pocket-case.  It  is  used  in  similar 
cases  as  the  lunar  caustic. 

Needles  (Fig.  32). — There  should  always  be  an  ample 
supply  of  surgical  needles,  both  straight  and  curved,  in  the 
pocket-case;  also  a number  of  common  sewing-needles,  and 

Fig.  32. 


Surgical  needles. 


such  pins  as  are  used  by  the  entomologist,  for  the  twisted 
suture.  The  needles  ought  to  be  kept  bright  and  clean 
by  smearing  them  with  a little  mercurial  ointment  before 
being  put  away. 

The  exploring  needle  (Fig.  33)  is  of  large  size  and 
grooved,  mounted  upon  a handle  which  at  the  same  time 

Fig.  33. 


Exploring  needle. 

forms  a sheath  for  it  when  not  in  use.  The  exploring 
trocar  (Fig.  34)  is  simply  a long  needle  furnished  with  a 
tube  like  the  ordinary  trocar.  These  instruments  enable 
the  surgeon  to  explore  the  nature  of  tumors,  and  to  remove 
a specimen  from  their  interior.  The  greatest  discrimination 
should  be  exercised  in  employing  them,  as  great  injury 
may  be  done  the  patient  by  the  injudicious  puncturing  of 
certain  morbid  growths. 

The  Artery  Needle  is  a curved  metallic  stem,  with  a 
broad-eyed  point,  mounted  upon  a handle,  in  the  manner 


44 


OF  THE  FIRST  PIECES  OF  DRESSING. 


Fig-  35.  of  a tenaculum.  It  serves  the  purpose  of 

passing  a ligature  around  an  artery. 

Catheters  (Fig.  35). — There  should  he  at 
least  two  male  and  a female  catheter  in  the 
pocket-case.  For  portability,  they  are  made 
in  short  sections  fitting  to  each  other.  The 
tubes  are  of  silver,  and  consist  of  a main  stem 
or  body  four  or  five  inches  long,  the  free  end 
of  which  has  two  little  rings  soldered  to  its 
sides,  for  the  attachment  of  a retentive  band- 
age; the  other  end  is  bevelled  to  receive 
three  different  shaped  beaks : the  first  is  short 
and  slightly  curved,  and  converts  the  tube 
into  a female  catheter ; the  other  two  are  long 
and  very  much  curved,  and,  being  of  different 
sizes,  supply  the  surgeon  respectively  with  a 
No.  7 and  a No.  3 male  catheter.  The  bevel 
upon  the  distal  end  of  the  main  stem  pre- 
vents the  beaks  rotating,  while  they  are  kept 
from  slipping  off  the  body  by  means  of  a 
catheters.  male  screw  cut  upon  the  extremity  of  a se- 

cond tube,  C,  running  through  the  body,  and 
working  in  the  female  screws  of  the  beaks.  W e shall  consider  the  man- 
ner of  using  these  instruments  under  the  head  of  catheterism. 


Fig.  36. 


Besides  the  foregoing  instruments,  a supply  of  saddler's 
silk,  and  iron,  lead,  and  silver  suture  wire,  ought  to  be  ready. 
To  prevent  them  tangling,  which  they  are  exceedingly  apt 
to  do  when  kept  in  the  skein  or  in  bundles,  they  should  be 
wound  around  a small  piece  of  wood  or  ivory,  similar  to  that 
seen  in  Fig.  36. 

The  pocket-case  ought  to  be  kept  in  perfect  order  and 
efficiency,  the  instruments  should  be  carefully  cleansed  after 
every  dressing  or  operation,  and  those  having  cutting  edges 
not  permitted  to  become  dull. 


CHAPTER  II. 

OF  THE  FIRST  PIECES  OF  DRESSING. 

Under  this  heading  we  propose  to  describe  the  kinds,  qualities,  and 
uses  of  certain  articles  which  are  usually  placed  in  direct  contact  with 
diseased  and  injured  surfaces,  and  therefrom  called  the  “first  pieces  of 
dressing .” 

Lint  is  employed  in  surgical  practice  under  three  different  forms — 
patent  lint,  charpie,  and  scraped  lint. 


CHARPIE. 


45 


Patent  Lint  is  prepared  by  the  manufacturer,  and  furnished  the 
profession  in  the  shape  of  rolls  five  yards  long  and  fifteen  inches  wide. 
It  may  be  described  as  a loosely-woven  cloth  of  coarse  hempen  fibres, 
with  one  of  its  sides  covered  with  a soft  tomentose  down;  the  other  is 
harsh,  and  glazed  by  sizing.  The  lint  is  well  adapted  to  the  various 
purposes  of  a surgical  dressing,  being  alone  objectionable  on  account 
of  its  expensiveness.  It  is  used  as  a direct  application  to  wounded 
surfaces,  either  saturated  with  water,  warm  or  cold,  or  spread  with 
cerate.  When  intended  to  act  as  an  absorbent,  all  greasy  substances 
should  be  kept  from  it;  but  for  this  purpose  it  is  not  nearly  so  good 
as  charpie.  Cut  into  pieces  of  various  shapes  and  sizes,  patent  lint 
possesses  a wide  range  of  application,  as  in  the  preparation  of  com- 
presses, lining  splints,  as  a vehicle  for  bringing  water  and  medicated 
solutions  in  contact  with  the  body,  protecting  ulcerated  surfaces  and 
absorbing  their  secretions. 

Charpie  is  perhaps  the  best  article  now  in  use  for  dressing  wounds, 
ulcers,  and  denudations.  Like  the  preceding  substance,  a high  price 
is  asked  for  it  by  the  manufacturers,  by  whom  it  is  made  in  large  quan- 
tities for  surgical  purposes.  It  may  be  easily  prepared,  as  required 
by  the  surgeon,  in  the  following  manner : Take  linen  of  moderate 
fineness,  white,  softened  by  use,  and  well  washed,  to  free  it  from  all 
impurities  (bleaching  preparations,  such  as  chlorine  and  chlorinated 
lime,  &c.,  should  not  be  used  to  cleanse  it);  cut  it  into  pieces  three  or 
four  inches  square;  hold  one  of  these  in  the  left  hand,  and  with  the 
right  ravel  it,  thread  by  thread,  and  throw  them  all  in  a heap.  If  the 
threads  are  too  short,  or  too  many  of  them  are  attempted  to  be  re- 
moved at  a time,  the  resulting  charpie  is  apt  to  be  knotty,  and  is  illy 
fitted  for  contact  with  delicate  surfaces. 

A coarser  and  longer-threaded  charpie  may  be  made  in  a similar 
mode,  and  used  for  padding  splints,  as  an  outer  dressing,  and  such 
like  purposes. 

When  prepared  in  the  way  above  directed,  charpie  forms  a soft, 
light,  and  cottony  mass,  free  from  knots  and  unequal  fibres.  Viewed 
through  a magnifying-glass,  each  thread  is  seen  to  be  wavy,  from  the 
mutual  pressure  of  the  fibres  by  the  crossing  of  the  woof  and  warp, 
and  is  covered  with  little  downy  hooks  which  fasten  into  each  other 
in  every  direction,  holding  the  filaments  lightly  together. 

Gerdy  states  that  new  linen  makes  a more  absorbent  charpie  than 
old.  This  may  be  true,  if  he  refers  to  very  old  cloth,  whose  fibres 
are  both  condensed  and  cleared  of  the  cottony  down  above  spoken  of; 
but  certainly  that  which  is  only  softened  by  wear  and  washing  is  more 
porous,  and  preferable  to  stiff  and  harsh-fibred  new  linen  for  preparing 
a smooth  and  absorbing  charpie. 

With  age,  charpie  changes  color,  becoming  yellow,  denser,  and 
therefore  less  absorbent  and  more  irritating  than  recent  charpie.  The 
material  should  be  kept  in  a dry  place,  and  out  of  the  atmosphere 
of  hospital  wards  rendered  impure  by  the  exhalations  from  diseased 
bodies,  foul  ulcers,  gangrenous  sores,  or  contagious  diseases  of  every 
kind.  Pelletan  attributed  the  hospital  gangrene  which  seized  upon 
the  wounds  of  a large  number  of  the  victims  of  the  bloody  days  of 


46 


OF  THE  FIRST  PIECES  OF  DRESSING. 


the  French  Revolution,  lying  in  the  Hotel  Dieu  of  Paris,  to  charpie 
so  exposed  and  used  in  dressing  their  wounds. 

Charpie  is  a gentle  excitant  of  the  surfaces  to  which  it  is  applied, 
raises  their  temperature,  and  absorbs  their  secretions  in  a direct  ratio 
with  the  thickness  of  the  mass  used.  It  takes  up  the  serous  portion 
of  pus  freely,  and  its  globules  less  so;  so  that  the  side  in  contact  with 
the  pus  will  be  found  covered  with  the  thickened  secretion,  while  the 
outer  surface  is  just  moistened  with  the  serum.  The  practice  of 
smearing  charpie  with  greasy  matters  materially  interferes  with,  or 
entirely  arrests,  absorption. 

For  the  purpose  of  answering  special  indications,  the  surgeon  fre- 
quently arranges  the  fibres  of  the  charpie  in  different  manners,  which 
we  shall  now  describe. 

The  Plumasseau  is  thus  formed : Hold  a mass  of  charpie  in  the 
palm  of  the  right  hand ; then,  with  the  thumb  and  the  radial  border 
of  the  left,  seize  the  ends  of  the  fibres,  and  draw  them  out  parallel 
upon  its  palmar  aspect.  Make  the  plumasseau  from  a quarter  to  an 
inch  thick,  according  to  the  amount  of  secretion  to  be  absorbed;  then 
cut  off  the  ends  of  the  threads  evenly,  or  fold  them  under.  Its  size 
and  shape  should  vary  with  the  dimensions  and  figure  of  the  part  to 
be  covered ; that  is,  it  must  be  round,  oval,  square,  or  quadrangular, 
according  to  the  requirements  of  the  case.  The  plumasseau  is  either 
applied  alone,  spread  with  cerates,  or  saturated  with  water  or  some 
medicated  solution.  Some  surgeons  have  impregnated  the  charpie 
with  various  gases — as  chlorine,  carbonic  acid  gas,  &c. — and  have  used 
it  in  certain  cases  with  supposed  advantage. 

The  Gateau  is  nothing  more  than  a large  plumasseau,  and  is  pre- 
pared in  the  same  form ; but  being  too  large  to  lie  upon  the  palm  of 
the  hand,  the  threads  are  drawn  out  upon  a table,  the  ulnar  border  of 
the  left  hand  being  used  to  retain  their  ends.  The  gateau  may  be 
made  more  expeditiously  by  taking  a mass  of  charpie  in  the  two 
hands,  and  moulding  it  with  the  fingers  in  the  desired  shape.  The 
gateau  forms  a large  loose  mass  well  fitted  to  constitute  the  upper 
layer  of  a dressing. 

The  Bullet  is  made  by  rolling  charpie  between  the  palms  of  the 
hands  in  balls  varying  in  size  from  a pea  to  an  egg,  in  proportion  to 
the  extent  of  the  cavity  to  be  filled.  When  the  bullet  is  intended 
for  the  purpose  of  absorbing,  it  should  be  light  and  open-textured; 
and  on  the  other  hand,  when  for  pressure,  as  to  arrest  hemorrhage,  it 
should  be  made  denser  by  hard  rolling. 

The  Roll  is  prepared  exactly  in  the  same  manner  as  the  bullet, 
with  the  exception  that  it  is  given  a spindle-shaped  or  cylin- 
drical form,  and  sometimes  slightly  compressed.  It  varies  in  size 
according  to  the  necessities  of  each  particular  case.  The  purposes 
which  the  roll  serves  are  chiefly  to  separate  abraded  or  ulcerated 
surfaces,  as  the  thighs  and  nates  in  intertrigo,  the  thighs  and  scrotum, 
and  the  labia  majora  when  they  are  ulcerated.  It  is  used  also  to 
keep  the  lips  of  those  wounds  apart,  that  we  do  not  desire  to  have 
healed. 

The  Bourdonnet  consists  of  a number  of  threads  rather  firmly 


SPONGE  TENT. 


47 


rolled  together  between  the  palms,  and  tied  together  at  their  centre 
with  a thread.  It  is  used  to  make  pressure  at  the  bottom  of  wounds 
or  cavities,  and  to  keep  the  margins  of  any  solution  of  continuity 
asunder.  The  free  thread  hangs  externally,  and  enables  the  surgeon 
to  remove  the  bourdonnet  from  its  bed. 

The  Pellet  is  a mass  of  charpie  inclosed  in  a piece  of  muslin,  and 
tied  at  its  upper  part,  so  as  to  form  a sort  of  stopper ; or,  again,  the 
muslin  may  be  introduced  into  any  cavity,  first,  and  then  the  lint 
stuffed  in  ; thus,  a very  large  space  with  a small  orifice  may  be  readily 
filled.  The  pellet  is  employed  to  make  pressure  in  hemorrhage  from 
the  rectum  and  the  intercostal  and  internal  pudic  arteries.  We 
should  be  careful  in  removing  the  pellet  not  to  pull  it  swollen  by  the 
absorption  of  blood,  or  the  secretions  from  the  wound,  but  rather 
to  open  the  muslin  bag,  and  with  a pair  of  forceps  pick  out  the  lint 
piece  by  piece. 

The  Tampon. — When  a number  of  separate  masses  of  charpie  are 
thrust  into  a cavity  or  wound  to  plug  it  up,  either  free  or  inclosed  in 
a little  pocket  of  linen,  a tampon  is  formed.  So  that  the  pellet, 
bourdonnet,  roll,  and  bullet  are  tampons  on  a small  scale  when 
they  are  employed  to  make  pressure  upon  bleeding  vessels.  Uterine 
hemorrhage  is  sometimes  treated  by  tamponing  the  vagina. 

The  Meche. — Place  a few  filaments  of  charpie  parallel  with  each 
other,  and  tie  them  together  at  the  centre  with  a thread,  then  double 
them,  so  that  all  the  ends  shall  meet.  It  should  be  trimmed  evenly, 
when  you  will  have  the  common  meche. 

The  linen  meche  consists  of  a strip  of  linen  an  inch  wide,  ravelled 
at  its  two  lateral  edges  into  a fringe  a quarter  of  an  inch  wide. 

The  cotton  meche  is  nothing  more  than  the  ordinary  round  lamp- 
wick. 

The  meche  may  be  had  recourse  to  for  dilating  fistulous  passages 
and  contracted  orifices. 

The  Tent.- — The  tent  is  now  scarcely  ever  used,  being  replaced  by 
the  much  more  elegant  and  convenient  meche. 

Should  it  be  desired,  however,  it  may  be  formed  of  charpie,  an  old 
piece  of  muslin,  any  porous  root,  the  gentian  or  flag,  for  instance,  or 
sponge. 

If  charpie  is  at  hand,  select  a few  fibres  of  it,  and  lay  them  parallel 
with  each  other ; then  double  them  to  bring  all  the  ends  together,  and 
give  the  cylinder  a twist  between  the  fingers  so  as  to  impress  upon  the 
fibres  a spiral  direction  and  a conical  form  ; or  a piece  of  soft  old  linen 
may  be  rolled  into  a cylinder  of  the  desired  size. 

Gentian,  carrot,  and  calamus  roots,  thoroughly  dried,  and  cut  into 
pieces  of  the  proper  size  and  shape,  will  answer  the  purposes  of  a tent. 

Sponge  Tent  is  prepared  by  soaking  soft  white  sponge  in  melted 
yellow  wax,  and  then  allowing  it  to  cool  under  pressure  between  two 
marble  or  metallic  slabs.  The  sponge  may  then  be  fashioned  with  a 
knife  as  desired. 

Some  surgeons  prefer  to  these  tents  narrow  strips  of  adhesive 
plaster  rolled  in  little  cylinders,  or  short  pieces  of  a gum  bougie  or 
catheter. 


48 


OF  THE  FIRST  PIECES  OF  DRESSING. 


The  ordinary  object  in  view  in  employing  tents  is  to  obtain  a 
dilating  effect  by  their  swelling  with  the  absorption  of  the  heat  and 
moisture  of  the  parts ; hence  they  have  been  used  to  dilate  contracted 
orifices  and  narrowed  canals.  The  objection  to  these  is  the  painful 
pressure  they  sometimes  exert,  and  the  blocking  in  of  secreted  fluids. 
For  procuring  a gentle  force,  the  tents  made  of  charpie  and  old 
linen  are  to  be  preferred.  Sponge  tent  acts  energetically  and  often 
causes  insupportable  pain ; it  is  sometimes  used  to  dilate  the  os  uteri. 

Scraped  Lint  is  the  soft,  fleecy,  and  light  down  scraped  from 
the  surface  of  old  linen  with  a moderately  dull  knife.  A piece  of 
this  kind  of  cloth  should  be  stretched  out  upon  a board,  and  its 
corners  fastened  down  with  tacks;  or  it  may  be  held  between  the  left 
hand  of  the  surgeon  and  the  hand  of  an  assistant,  while  with  his 
right  he  removes  the  lint  with  the  edge  of  the  knife. 

Viewed  with  a double  convex  lens  its  fibres  will  be  found  fine, 
short,  and  sharp  pointed,  and,  from  these  circumstances,  it  is  more 
irritating  than  other  kinds  of  lint,  though  more  absorbent.  This 
property  renders  it  an  appropriate  dressing  in  those  cases  of  flabby 
and  indolent  ulcers,  or  of  other  atonic  secreting  surfaces  which  require 
gentle  stimulation. 

In  domestic  practice,  cuts  and  sores  are  sometimes  dressed  with  the 
fine,  soft  down  scraped  from  an  old  fur  or  silk  hat ; it  absorbs  their 
moisture  and  forms  over  them  an  impermeable  crust  under  which 
the  healing  goes  on  by  what  Macartney  called  the  “ modelling  pro- 
cess.” 

Cotton. — The  softness,  cheapness,  and  general  diffusion  of  cotton 
have  for  a long  time  attracted  the  attention  of  surgeons,  and  induced 
them  to  apply  it  to  many  important  surgical  purposes. 

Mayor,  of  Lausanne,  states  his  belief  that  cotton  may  advanta- 
geously replace  all  kinds  of  lint,  while,  on  the  other  hand,  Gerdy  con- 
demns it  in  unmeasured  terms,  for  all  uses  other  than  as  an  external 
part  of  dressings,  and  for  padding  splints.  The  truth  seems  to  lie 
between  these  two  extremes;  for  Velpeau  and  Larrey  have  employed 
it  as  a direct  application  with  considerable  success  and  satisfaction. 
Anderson,  of  Glasgow,  lauds  cotton  highly  as  a dressing  for  burns ; 
and  Roux  thought  it  formed  an  excellent  covering  for  ulcers.  Every 
surgeon  will  readily  acknowledge  its  usefulness  as  an  incomparable 
article  out  of  which  the  softest  and  downiest  cushions  can  be  made 
for  supporting  an  injured  limb,  and  equalizing  the  pressure  of  splints. 

Examined  with  a magnifier  the  fibres  of  cotton  are  seen  to  be  long, 
rugged,  and  spirally  twisted,  interlacing  with  each  other  in  every 
direction.  It  is  quite  absorbent,  and  more  irritating  than  either 
patent  lint  or  charpie,  to  which  it  is  also  now  conceded  to  be  infe- 
rior as  an  immediate  dressing  for  Avounds. 

We  have  used  cotton  in  bed-sores,  by  spreading  sheets  of  it  under 
the  patient,  and  believe  that  a salutary  influence  is  exercised  upon 
their  surfaces  by  its  gently  stimulating  action.  It  has  one  objection, 
viz.,  a tendency,  when  soaked  with  the  secretions  from  the  sores,  to 
roll  up  in  hard  and  irritating  knots,  which  cause  great  discomfort  to 
a patient.  However,  it  certainly  ranks  next  to  lint  in  value  as  a 


OAKUM — TOW — WOOL  — RAW  SILK. 


49 


dressing,  and  in  the  absence  of  the  latter  may  serve  as  a substitute. 
It  is  invaluable  for  maintaining  an  elevated  temperature  in  parts  de- 
prived of  their  vascular  supply  by  the  ligature  of  the  main  artery,  or 
other  causes. 

Cotton  is  found  in  commerce  ready  for  use,  in  sheets  neatly  rolled 
up  in  cylindrical  bundles. 

Oakum.- — Lately  this  article  has  been  much  used  in  the  treatment 
of  suppurating  gunshot  wounds,  and  is  particularly  praised  for  this 
purpose  by  Dr.  Sayers,  of  New  York.  He  simply  confines  the  oakum 
to  the  wounded  part  by  a roller  bandage.  Seamen  have  for  years 
been  in  the  habit  of  employing  it  as  a direct  application  to  the  wounds 
and  injuries  incidental  to  their  calling. 

Oakum  is  prepared  by  tearing  old  tarred  rope  into  threads ; the  tar 
which  permeates  it  confers  stimulant,  astringent,  and  antiseptic  pro- 
perties, and  on  account  of  the  latter  quality  particularly,  is  preferable 
to  tow  in  cases  where  the  secretions  are  fetid. 

The  fibres  of  oakum  are  coarse,  rough,  and  very  unfriendly  to  sen- 
sitive granulating  surfaces,  and  for  this  reason  should  generally  be 
laid  over  a thin,  interposing  layer  of  charpie.  It  absorbs  pus  only 
moderately. 

For  use  the  oakum  is  moulded  with  the  fingers,  in  the  form  of  a 
gateau  of  the  proper  size  to  cover  the  wounded  part,  and  retained  in 
position  by  a few  lightly  applied  turns  of  a roller. 

Tow. — As  an  outer  dressing  to  absorb  profuse  secretion  and  to  level 
inequalities  of  the  limbs  for  the  application  of  splints,  tow  forms  an 
excellent  material.  Its  fibres  are  coarse,  harsh,  and  irregular,  which 
unfit  them  for  the  purposes  to  which  lint  is  so  admirably  adapted. 
Various  degrees  of  fineness  are  possessed  by  tow  as  found  in  commerce, 
the  coarser  varieties  made  from  hemp  should  be  rejected  for  the  soft 
and  elastic  article  prepared  by  the  process  of  hatckelling  flax. 

Tow  is  employed  in  the  form  of  gateau  in  the  same  manner  as 
oakum. 

Wool. — From  its  irritating  qualities,  comparative  scarcity,  cost, 
and  general  inadaptability  for  surgical  dressings,  wool  can  never  take 
the  precedence  of  any  of  the  above-mentioned  articles  when  obtain- 
able ; however,  when  wrought  into  cloth,  its  elasticity,  and  warmth- 
preserving properties  highly  recommend  its  application,  in  the  form 
of  rollers,  to  limbs  suffering  from  defective  circulation  and  nutrition, 
instead  of  muslin. 

Baw  Silk  is  here  suggested  rather  as  an  attainable  substitute  for 
lint,  tow,  &c.,  in  those  countries  where  the  article  can  be  obtained  both 
cheaply  and  abundantly,  and  in  the  absence  of  more  appropriate  mate- 
rials, naval  medical  officers  cruising  in  the  East  Indies  can  make  this 
answer  as  a dressing.  I used  it  in  Japan ; but  the  length,  density, 
smoothness,  and  little  absorbing  power  of  its  fibres  did  not  recommend 
its  continuance  when  a supply  of  other  articles  was  on  hand. 

The  same  remarks  apply  to  the  downy  substance  enveloping  the 
seeds  of  the  silk-cotton  tree,  a large  plant  of  the  genus  Bombyx  growing 
both  in  the  East  and  W est  Indies. 

For  padding  splints  I have  made  some  trials  with  the  cottony,  or 

4 


50 


OF  THE  FIRST  PIECES  OF  DRESSING. 


rather  silky  matter  (aigrette),  attached  to  the  seeds  of  the  Asclepias 
Syriaca,  or  Milkweed,  an  herbaceous  plant  growing  abundantly  in  the 
neglected  fields  throughout  Pennsylvania.  As  it  costs  nothing,  and 
answers  as  well  as  the  finest  cotton,  the  attention  of  rural  practitioners 
ought  to  be  drawn  to  the  advantages  which  may  be  made  to  spring 
from  its  introduction  into  surgical  practice. 

It  does  not  irritate  wounds,  and  will,  therefore,  serve  as  a direct 
dressing;  in  experiments  made  by  me  to  ascertain  its  absorbing  power, 
I found  it  to  be  equal  to  that  of  raw  cotton. 

Sponge  is  rarely  used  as  a dressing,  though  the  late  Dr.  Valentine 
Mott  entertained  a high  opinion  of  its  value  as  a powerful  absorbent, 
and  as  a dressing  in  profuse  suppurations  and  compound  fractures. 
The  compression  obtained  by  binding  large  pieces  to  flaccid  and 
uneven  surfaces  has  been  highly  commended  by  several  surgeons. 
Sponge  is  harsh  textured,  and  not  generally  agreeable  to  the  feelings 
of  a patient.  The  granulations  developed  from  the  surface  of  ulcers, 
are  apt  to  shoot  into  its  pores,  and  thus  render  the  removal  of  the 
dressing  both  injurious  and  painful. 

Moss. — A fine  quality  of  moss,  in  emergencies,  has  been  used  as  a 
dressing;  and  in  countries  where  it  grows  abundantly  upon  the  trunks 
and  limbs  of  trees,'  as  along  the  banks  of  the  Mississippi  River,  it  may 
be  made  available  for  filling  up  inequalities  of  the  surface  of  the 
body,  and  for  making  soft  cushions  to  be  used  in  the  treatment  of 
fractures. 

Cat’s-tail,  or  Typha  (Typha  latifolia). — Cat’s-tail  has  been  for  a 
long  time  employed  in  domestic  practice,  in  some  parts  of  Europe,  as 
a substitute  for  cotton  in  burns,  ulcers,  and  wounds.  It  is  prepared 
by  beating  the  cylindrical  tops  of  the  flag  against  the  edge  of  a board, 
whereby  a soft  and  whitish  brown,  downy,  porous  matter  is  obtained. 
It  absorbs  readily,  but  the  fibres  are  short  and  sharp,  and  often  pro- 
duce considerable  irritation  of  the  wound  to  which  it  is  applied,  and 
they  adhere  so  tenaciously  to  them  as  to  render  their  removal  difficult. 

The  typha  grows  abundantly  in  the  marshes  throughout  the  South- 
ern States,  and  is  used  by  the  country  people  for  making  beds  and 
pillows.  At  the  temporary  naval  hospital,  located  during  the  late 
war  at  the  delta  of  the  Mississippi  River,  where  this  flag  grows  in 
the  greatest  plenty,  during  a period  of  great  scarcity  of  surgical 
dressings,  soft  pillows  for  fractured  limbs  to  repose  upon,  pads  for 
splints,  and  a variety  of  useful  articles,  were  prepared  from  cat's-tail. 

Amadou  (spunk,  or  punk). — Amadou  and  spunk  are  two  porous, 
fungous  vegetable  growths,  found  adhering  to,  and  deriving  their 
support  from  the  juices  of  the  oak,  birch,  willow,  and  other  trees, 
and  have  been  at  times  highly  commended  as  surgical  dressings. 
Mr.  Wetherfield  ( Loncl . Med.  Gaz.,  1841)  states  that  the  amadou  or 
German  tinder  forms  an  excellent  elastic  medium  for  applying  support 
and  pressure,  and  as  a defence  to  tender  and  delicate  parts,  as  in 
the  form  of  a graduated  compress  in  umbilical  hernia  of  new-born 
infants,  and  as  a compress  over  fistulous  ulcers  of  the  groin.  It  does 
not  lose  its  elasticity  like  lint.  In  preparing  it  we  select  such  pieces  as 
are  firm,  smooth,  and  of  uniform  density,  cut  them  in  slices,  and  then 


METALLIC  PLATES. — COMPRESSES. 


51 


by  beating  with,  a mallet  render  them  soft  and  pliant.  Recamier’s 
plan  of  employing  it  in  the  treatment  of  cancer  will  be  considered 
farther  on. 

Bran. — We  are  indebted  to  Dr.  J.  Rhea  Barton,  for  the  introduc- 
tion of  bran  into  surgical  practice ; he  generally  used  it  in  compound 
fractures  of  the  leg,  but  it  may  be  made  available  in  the  treatment  of 
wounds  of  the  soft  parts.  It  is  an  elegant,  light,  and  cool  dressing, 
and  particularly  useful  in  hot  weather.  The  bran  should  be  heaped 
up  over  the  broken  limb  contained  in  a fracture  box,  so  that  the  flies 
cannot  deposit  their  ova  in  the  wounds,  and  produce  maggots. 

Sawdust. — I have  used  moderately  coarse  pine  sawdust  with  the 
most  pleasing  results,  in  the  same  manner  as  the  bran,  and  think,  after 
a considerable  experience,  that  as  a cool,  cheap,  and  very  absorbent 
article,  we  know  of  no  substance  superior  to  it  for  forming  a bed  upon 
which  to  rest  profusely  suppurating  stumps.  About  a quart  of  the 
dust  may  be  spread  upon  a square  piece  of  muslin,  the  stump  placed 
upon  it,  and  the  ends  reflected  over  the  limb  and  pinned  together. 
In  this  manner  one  dressing  will  generally  do  for  a whole  day,  no 
inconsiderable  advantage  in  an  overcrowded  hospital,  near  the  battle 
ground,  or  with  a small  number  of  medical  officers,  a condition  of 
things  not  very  uncommon  during  the  late  war. 

Metallic  Plates. — In  the  treatment  of  flabby  ulcers,  and  wounds 
requiring  some  stimulation,  metallic  plates  have  been  tried,  particu- 
larly those  of  tin,  or  tin,  antimony  and  lead,  or  simply  lead,  such  as 
are  to  be  found  in  tea-boxes.  We  obtain  the  advantages  of  compres- 
sion, and  of  the  chemical  action  of  the  soluble  salts  formed  upon  the 
surfaces  of  the  plates,  by  the  contact  with  the  secretions.  Doubtless 
the  electrical  currents,  which  are  always  developed  by  such  combi- 
nations, may  have  a share  in  their  beneficial  influence. 

The  metallic  plates  are  simply  cut  and  bent  into  the  appropriate 
size  and  shape  of  the  surface  to  be  covered,  a layer  of  lint  then  placed 
over  them  to  absorb  the  secretions,  and  the  whole  confined  by  turns 
of  a roller  bandage. 

Compresses. — -It  will  be  useful  to  have  square  pieces  of  muslin, 
linen,  and  flannel  at  hand,  for  the  purpose  of  making  those  compresses 
of  various  forms  which  the  surgeon  commonly  avails  himself  of  in 
dressing.  For  immediate  contact  with  wounds,  the  material  should 
be  soft,  and  partially  worn  linen ; flannel  may  be  used  in  those  cases 
where  its  properties  of  elasticity  and  absorbability  are  required.  It 
will  also  be  economical,  and  answer  just  as  well,  to  employ  muslin  for 
equalizing  the  surfaces  of  parts,  and  where  the  skin  is  unbroken. 

Besides  these  materials,  raw  cotton,  tow,  and  other  similar  articles 
are  sometimes  made  use  of  as  compresses. 

A compress  answers  other  indications  than  mere  compression,  which 
its  etymological  import  would  seem  to  imply.  It  may  be  simply  pro- 
tective, as  when  we  place  a layer  of  soft  linen  between  two  opposing 
surfaces  to  get  rid  of  the  ill  effects  of  friction,  or  cover  a wound  to 
shield  it  from  external  irritants ; or  to  ward  oft’  the  pressure  of  splints  ; 
again  a compress  may  be  said  to  be  retentive  only  when  it  holds  other 
dressings  in  place. 


52 


OF  THE  FIRST  PIECES  OF  DRESSING. 


Compresses  have  been  divided  by  Velpeau  into  three  classes,  the 
simple,  the  split,  and  the  folded. 

1.  Simple  Compresses. — The  square  or  ordinary  compress  is  formed 
by  folding  a piece  of  cloth,  with  a length  of  double  its  breadth,  upon 
itself;  all  its  sides  are  equal. 

When  the  square  is  folded  diagonally  so  as  to  bring  two  of  its  angles 
together,  the  triangular  compress  results ; then  by  placing  the  apex  of 
the  latter  upon  its  base,  and  folding  once,  the  cravat  compress  is 
formed. 

The  square  doubled  once,  gives  the  oblong  compress,  and  this  folded 
again,  the  “longuette”  compress. 

The  perforated  compress  is  prepared  by  piercing  a piece  of  cloth  with 
numerous  holes,  either  with  the  points  of  the  scissors,  or  a punch 
which  removes  small  circular  bits;  the  latter  object  may  also  be  more 
conveniently  and  expeditiously  accomplished  with  the  edges  of  the 
scissors : holding  the  cloth  in  the  left  hand,  and  shoving  up  small 
folds  with  the  point  of  the  index  finger,  clip  them  off.  This  compress 
is  usually  spread  with  cerate  to  prevent  other  dressings  adhering  to 
the  wound,  and  necessitating  painful  tractions  for  their  removal.  An- 
other of  its  advantages  is  to  allow  the  free  emission  of  pus. 

The  fenestrated  compress  results  from  the  cutting  out  of  a piece  of 
cloth,  of  an  oval,  square,  or  triangular  shape  near  the  centre  of  the 
muslin. 

This  is  used,  sometimes,  to  remove  hurtful  pressure  from  any  part 
of  the  surface,  as  in  burns  and  corns;  to  limit  the  action  of  caustics, 
and  to  dress  certain  ulcers. 

When  the  square  compress  is  twice  folded,  and  the  free  angles  re- 
moved in  the  direction  of  a curved  line  between  the  upper  and  lower 
angles,  the  round  compress  results,  which  may  then  be  either  perfo- 
rated, fenestrated,  or  fringed,  so  as  to  allow  its  edges  to  adapt  itself 
accurately  to  the  irregular  outlines  of  any  part. 

2.  Split  Compresses  are  formed  by  making  slits  in  the  sides,  centre, 
on  ends  of  strips  of  cloth  of  different  widths  and  lengths.  The}-  are 
denominated  the  button-hole,  the  single-split,  the  double-split,  the 
many-split,  and  sling-compresses,  the  half  Maltese  cross,  and  Maltese 
cross.  The  button-hole  compress  has  simply  a slit  in  its  centre ; the 
single-split,  or  compress  with  two  tails,  is  a piece  of  muslin  slit  up  from 

one  end  to  its  centre;  the  double-split, 
as  its  name  indicates,  is  divided  in  the 
same  manner  by  two  slits,  into  three 
tails.  The  two  latter  compresses  are 
more  commonly  called  retractors,  and 
are  used  almost  exclusively  in  amputa- 
tions to  press  back  the  soft  parts  while 
the  bones  are  being  sawed  through; 
the  former  when  the  limb  has  a single 
bone,  and  the  latter  compress  when 
there  are  two  bones.  The  many-split 
compress  is  prepared  by  slitting  the 
two  sides  of  a piece  of  muslin  into  a 


Fig.  37. 


The  many-tailed  bandage. 


COMPRESSES. 


53 


Fig.  38. 


number  of  tails  (Fig.  37),  leaving  an  intermediate  uncut  portion  or 
body.  A modification  of  this  is  what  is  known  as  the  bandage  of 
Scultetus,  consisting  of  separate  strips  overlapping  each  other  a half 
or  two-thirds  of  their  width.  When  these  strips  are  tacked  together 
with  thread  and  needle  along  their  middle,  Pott’s  bandage  is  formed. 

The  eighteen- tailed  bandage,  so  called  by  Yerduc,  consists  of  three 
pieces  of  muslin,  equal  in  size  and  of  the  desired  width,  laid  one  upon 
another  and  fastened  along  the  centre  with  thread  and  needle;  then 
with  the  scissors  each  of  its  two  sides  is  split  into  three  tails.  The 
many-tailed  bandage  employed  by  Dupuytren  was  made  of  nine  sepa- 
rate strips,  sewed  together  at  their  centre,  after  having  been  imbri- 
cated in  the  usual  manner. 

These  different  forms  of  the  many-tailed  bandage  have  been  chiefly 
employed  in  making  compression  upon  the  limbs  after  having  been 
fractured,  and  before  the  application  of  the  other  portions  of  the  dress- 
ing ; although,  in  many  other  cases,  they  will  be  found  exceedingly 
neat  and  convenient  to  retain  poultices,  or  other  dressings  upon  dis- 
eased or  injured  extremities.  The  bandage  of  Scultetus  is  particularly 
adapted  to  this  purpose,  for  the  reason  that  any  portion  of  it,  when 
soiled,  may  be  removed  without  disturbing  the  rest.  Their  mode  of 
application  is  the  same,  viz : to  spread  the  bandage  out  upon  the  bed, 
and  then  to  lay  the  limb  upon  it 
and  bring  up  the  strips  alternately 
from  side  to  side,  imbricating  them 
smoothly,  until  the  leg,  or  whatever 
part  it  may  be,  is  covered  in. 

When  applied  moist  for  the  pur- 
pose of  making  compression,  the 
surgeon  cannot  watch  them  too  nar- 
rowly; for  the  most  disastrous  con- 
sequences have,  on  several  occa- 
sions, resulted  from  their  producing 
excessive  constriction,  either  by  the 
subsequent  swelling  of  the  parts  on 
which  they  are  placed,  or  by  the 
contraction  of  the  bandage  itself,  or 
both  causes  combined. 

The  sling -compress  is  a long  strip 
of  muslin  or  other  material,  divided 
from  each  of  its  extremities  to 
within  three  or  four  inches  of  the 
centre. 

It  is  principally  used  in  the  treat- 
ment of  fractures  of  the  lower  jaw, 
and  for  confining  dressings  to  the 
joints. 

The  half  Maltese  cross  is  formed 
by  folding  a square  compress  upon  itself,  and  cutting  with  the  scissors 
diagonally  from  either  of  the  corners  formed  by  the  free  angles, 
towards  the  centre  of  the  opposite  folded  side. 


54 


OF  THE  FIRST  PIECES  OF  DRESSING. 


The  half  Maltese  cross  is  sometimes  employed  to  retain  dressings 
upon  the  shoulder  after  amputation. 

The  Maltese  cross  (Fig.  89),  in  like  manner,  may  be  made  from 
a square  compress  folded  twice  upon  itself 
in  opposite  directions,  by  cutting  diagonally 
from  the  corner  where  all  the  free  angles 
meet,  towards  the  opposite  folded  angle  and 
within  a short  distance  of  it. 

This  compress  is  had  recourse  to  as  a reten- 
tive of  other  dressings  upon  stumps  after 
amputation,  and  also  upon  the  mamma. 

The  fringed  compress  is  a slip  of  linen  from 
a few  lines  to  an  inch  in  width,  incised  upon  one 
border  only  into  a sort  of  fringe.  It  is  spread 
with  cerate,  and  applied  to  the  circumference  of  wounds,  with  its 
points  outwards  to  prevent  the  charpie,  lint,  or  other  dressings  adher- 
ing to  them. 

3.  Folded  compresses  are  prepared  bv  folding  layer  after  layer  of 
lint,  muslin,  or  linen  upon  each  other  in  different  manners. 

When  these  folds  are  of  equal  width,  it  is  called  the  regular  graduated 
compress;  when,  on  the  contrary,  the  folds  are 
shortened  upon  one  side,  the  single  graduated 
compress  (Fig.  40)  results;  and  when  the  folds 
gradually  diminish  in  width  upon  both  sides,  we 
obtain  the  double  graduated  compress  (Fig.  41). 

The  pyramidal  compress  is  made  by  piling  up 
square  pieces  of  any  kind  of  cloth  upon  each 
other,  each  being  smaller  than  its  predecessor, 
until  a sufficient  thickness  is  obtained.  If  these 
pieces  are  round,  the  compress  will  of  course  be 
conical. 

_ „ „ These  compresses  are  useful  when  firm  pres- 

Folded  compresses.  . . 1 n . A, . 

sure  is  required  either  over  a given  point,  line, 
or  limited  area;  as,  for  instance,  to  restrain  hemorrhage  from  the 
temporal  and  brachial  arteries  after  being  wounded  in  the  operation 
of  bleeding,  or  from  the  arteries  of  the  palmar  arch ; to  exercise 
compression  upon  morbid  growths,  aneurisms,  and  along  the  course 
of  fistulous  canals,  or  over  abnormal  cavities ; and  to  force  from 
their  nidus  pus  or  other  diseased  secretions. 

Often  for  the  purpose  of  retaining  dressings  upon  the  body,  con- 
fining fracture  apparatus,  securing  the  limbs  of  patients  about  to 
undergo  certain  surgical  operations,  such  as  lithotomy,  threads,  cords, 
straps,  and  strips  of  muslin  are  employed  by  the  surgeon.  They  will 
be  considered  in  their  appropriate  places,  throughout  this  work,  in  con- 
nection with  the  bandages,  apparatus,  instruments,  and  surgical  pro- 
cedures to  which  they  specially  appertain. 

Bandages  are  secured  by  means  of  pins  and  threads ; and  as  the 
latter  are  connected  together  by  knots,  some  of  which  are  in  frequent 
use  by  the  surgeon,  it  may  not  be  inappropriate  to  give  figures  of 
them. 


Fig.  40.  Fig.  41. 


COMPRESSES. — KNOTS. 


55 


The  surgeon's  knot  is  seen  in  Fig.  42,  and  was  formerly  employed 
\ithen  a thread  was  tied  around  an  artery.  The  single  low  knot  (Fig. 


Fig.  42.  Fig.  43.  Fig.  44. 


43)  and  the  double  bow  knot  (Fig.  44)  are  in  constant  use  for  fastening 
the  muslin  strips  around  fracture  apparatus,  and  the  threads  securing 
the  little  bandages  about  the  fingers  and  toes.  The  single  knot  (Fig. 
45)  and  the  double  knot  (Fig.  46)  are  used  for  like  purposes. 


Fig.  45.  Fig.  46.  Fig.  47. 


The  loop  knot  (Fig.  47)  will  answer  to  arrest  the  venous  circulation 
during  venesection,  and  enables  the  operator  to  graduate  the  com- 
pression instantly  and  accurately. 

The  packer's  knot  (Fig.  48)  is  the  one  formed  over  the  temple  by 
the  knotted  bandage  of  the  head. 

The  clove  hitch  (Fig.  49),  used  in  applying  the  extending  bands  for 


Fig.  48. 


Fig.  49. 


Fig.  50. 


the  reduction  of  dislocations,  consists,  as  seen  in  the  figure,  of  two 
packer’s  knots  laid  together. 

The  single  noose  (Fig.  50)  and  double  noose  (Fig.  51)  are  employed 
by  the  surgeon  to  secure  the  hands  and  feet  of  a patient  about  to 
undergo  the  operation  of  lithotomy. 

The  reef  or  sailor's  knot  (Fig.  52)  is  the  one  mostly  used  by  surgeons 
of  the  present  day  for  ligaturing  arteries  instead  of  the  surgeon’s  knot, 


56 


OF  THE  FIRST  PIECES  OF  DRESSING. 


for  the  reason  of  its  less  liability  to  slip,  and  the  certainty  with  which 
it  closes  the  arterial  canal.  The  case  of  Chopart,  as  related  by  Boyer, 


Fig.  51. 


Fig.  52. 


Fig.  53. 


is  well  known : that  distinguished  surgeon  lost  a patient  from  hemor- 
rhage, in  operating  for  popliteal  aneurism,  after  three  ligatures  had 
been  placed  upon  the  artery  and  tied  with  the  surgeon’s  knot.  An 
examination  showed  the  vessel  to  be  healthy,  but  not  closed  by  either 
of  the  knots. 

Fig.  53  shows  the  weaver's  knot;  Figs.  54  and  55  are  forms  of  the 


simple  slip  knot;  Figs.  56  and  57  are  the  double-knotted  and  looped,  and 
the  crossed  slip-knots. 

Adhesive  Plaster. — This  article  is  of  the  utmost  importance  to 
the  surgeon,  being  constantly  in  demand  for  the  treatment  of  various 
diseases  and  injuries  which  are  alwa}rs  presenting  themselves  in  the 
daily  routine  of  practice.  It  is  now  supplied  the  profession  by  manu- 
facturing druggists  in  rolled  sheets  ten  yards  long  and  sixteen  inches 
wide.  The  mode  of  preparation  consists  in  spreading,  by  means  of 
machinery,  the  emplastrum  resinre  of  the  Pharmacopoeia  (a  compound 
of  lead  plaster  and  resin  in  the  proportion  of  six  parts  of  the  former 
to  one  of  the  latter)  upon  sheets  of  muslin  or  linen. 

Ordinarily  the  plaster  is  employed  in  strips,  yet  for  special  purposes 
it  may  be  cut  with  the  scissors  into  any  shape  that  may  be  demanded. 
The  strips  should  be  severed  evenly  and  smoothly,  and,  to  attain  this 
object,  the  best  plan  will  be  to  unroll  the  sheet  to  the  extent  required 
by  the  length  of  the  strips,  and  stretch  it,  by  an  assistant  taking  charge 


ADHESIVE  PLASTER. 


57 


of  the  roll,  and  the  surgeon  of  its  free  end  with  the  left  hand,  in  such 
a manner  that  the  thumb  and  index  finger  support  the  extremity  of 
the  strip,  while  the  middle  and  index  fingers  uphold  that  part  of  the 
sheet  beyond.  Then  with  the  scissors  make  a small  cut  into  the 
border  of  the  plaster,  between  the  fingers,  and  holding  their  blades 
half  open,  press  them  along  the  cloth  towards  the  assistant. 

Although  it  is  customary,  when  the  roll  is  sufficiently  ample,  to  cut 
the  plaster  crosswise,  or  in  the  woof,  yet  it  is  always  preferable  to 
follow  the  warp,  or  the  large  threads  running  lengthwise,  for  the 
reason  that  strips  prepared  in  the  latter  way  yield  less  to  an  extending 
force,  and  in  a more  uniform  manner.  In  fact,  where  there  is  much 
resistance  expected  they  should  be  made  in  no  other  way. 

The  strips  thus  provided,  to  prevent  any  giving,  ought  to  be  sepa- 
rately stretched  before  being  applied,  and  then  warmed  to  enable 
them  to  adhere  immediately  to  the  skin.  A moderately  long  and 
narrow  strip  may  be  sufficiently  warmed  by  drawing  it  rapidly 
through  the  fingers.  The  flame  of  a candle  will  answer  the  same 
purpose,  but  the  strip  is  apt  to  be  blackened  by  the  carbonaceous 
matters  of  the  flame.  The  neatest,  best,  and  most  convenient  plan  of 
all  is  to  soften  the  plaster  by  applying,  for  a few  moments,  the  backs 
of  the  strips  to  a tin  vessel  filled  with  hot  water. 

Adhesive  plaster  is  adapted  to  a great  variety  of  cases,  and  serves 
many  useful  purposes ; among  others,  to  retain  dressings,  splints,  lint, 
and  compresses  upon  the  surface ; to  make  compression,  and  to  exer- 
cise a slightly  stimulating  effect  upon  ulcers  of  the  extremities, 
chronic  swellings  of  the  joints,  and  upon  indolent  tumors;  sometimes 
it  forms  the  whole  of  the  retentive  apparatus  in  certain  fractures. 

The  stimulating  effects  of  ordinary  plaster  sometimes  render  it  an 
objectionable  dressing  in  fresh  wounds,  and  where  the  integuments  are 
exceedingly  sensitive,  as  they  occasionally  are ; under  such  circum- 
stances it  may  induce  erythema,  or  even  erysipelas.  To  obviate,  in  a 
measure,  the  irritation,  Mr.  Baynton  employed  a plaster  containing 
only  six  drachms  of  resin  to  the  pound  of  lead-plaster.  With  the 
same  view,  M.  Herpin  recommends  the  addition  of  the  tannate  of  lead, 
the  proportion  of  which  should  not  exceed  one-twentieth. 

When  properly  made,  and  fit  for  surgical  use,  the  plaster  should 
not  crack  or  drop  off  the  muslin  in  flakes,  or  adhere  to  the  skin  when 
the  strips  are  removed.  The  plaster  may  be  rendered  more  pliable, 
and  prevented  from  cracking  in  very  cold  weather,  by  the  addition  of 
a small  proportion  of  soap,  which  is  far  preferable  to  those  cheaper 
and  more  irritating  articles,  sometimes  added  for  this  purpose,  Bur- 
gundy pitch  and  oil  of  turpentine. 

An  adhesive  plaster,  prepared  with  the  latter  substance,  was  once 
supplied  a hospital  under  my  charge  during  the  late  war ; and  after 
three  or  four  trials  I was  compelled  to  abandon  its  use  in  consequence 
of  its  irritating  qualities.  As  age  diminishes  its  adhesiveness,  the  sup- 
ply should  often  be  replenished. 

After  the  strips  have  been  removed  the  surface  may  be  cleared  from 
all  adhering  matters  with  a sponge  moistened  with  the  oil  of  turpen- 


58 


OF  THE  FIRST  PIECES  OF  DRESSING. 


tine,  and  when  the  oil  has  been  cleared  off  by  castile  soap  and  water, 
the  parts  may  be  dried  with  a soft  towel. 

Isinglass  Plaster  was  brought  into  notice  by  Mr.  Liston,  who 
says:  ‘'Of  late,  I have  greatly  dispensed  with  stitches  and  the  com- 
mon adhesive  plaster,  using,  instead  of  the  latter,  slips  of  glazed  ribbon 
smeared  with  a saturated  solution  of  isinglass  in  brandy,  which  is 
much  less  irritating  and  more  tenacious  than  the  common  adhesive 
compost.” 

Subsequently,  for  the  ribbon  he  substituted  the  peritoneal  covering 
of  the  caecum  of  the  ox,  rubbed  down  and  polished. 

As  now  found  in  the  shops  it  is  in  rolled  sheets,  three  yards  long  and 
eight  inches  wide.  Should  the  surgeon  desire  to  make  it  himself,  the 
following  is  the  formula.  Moisten  one  ounce  of  pure  isinglass  (the 
dried  swimming  bladder  of  several  species  of  fish  belonging  to  the 
genus  Acipenser)  with  two  ounces  of  water,  and  permit  it  to  stand 
until  it  is  quite  soft ; then  add  three  and  a half  ounces  of  rectified 
spirits,  previously  mixed  with  one  and  a half  ounce  of  water.  Place 
the  vessel  in  boiling  water  until  the  solution  is  complete,  and  about 
the  consistence  of  jelly,  wrhen  it  is  ready  for  use.  Now  spread  the 
oiled  silk  upon  a table,  tack  down  its  ends,  and  with  a brush  apply 
the  solution  to  its  surface  ; when  this  is  dry,  another  coat  may  be  laid 
on  and  permitted  to  dry.  The  plaster  is  then  fit  for  use. 

The  advantages  claimed  for  it  are  that  it  is  unirritating;  possess- 
ing some  degree  of  translucency,  the  parts  beneath  may  be  always 
inspected,  and  finally,  it  does  not  soften  in  extremely  warm  weather. 
The  latter  quality  will  render  it  a valuable  article  to  the  naval  sur- 
geon cruising  in  hot  climates.  The  drawback  to  its  general  use  will 
be  the  facility 'with  which  it  is  loosened  by  the  contact  of  the  warm 
secretions  of  the  parts  to  which  it  is  applied. 

The  mode  of  using  it  is  to  cut  the  plaster  in  strips,  and,  after  moist- 
ening their  gummed  sides  with  a sponge  squeezed  out  of  hot  water, 
lav  them  on  as  you  would  the  ordinary  adhesive  strips. 

Collodion. — This  was  first  suggested  as  an  agglutinative  by  Mr. 
Maynard,  of  Boston,  a medical  student.  It  is  a solution  obtained  by 
dissolving  gun-cotton,  on  pyroxylin,  in  a mixture  of  rectified  ether  and 
alcohol,  in  the  proportion  of  about  16  parts  of  the  former  to  one  of  the 
latter. 

When  applied  to  the  surface  it  produces  a sensation  of  coolness  by 
the  evaporation  of  the  ether,  and  leaves  behind  a translucent,  con- 
tractile, and  adhesive  film.  To  prevent  the  puckering  up  of  the  skin, 
which  follows  the  application  of  the  collodion,  it  has  been  suggested 
that  one  part  of  the  oil  of  turpentine  be  added  to  every  twenty  of 
ether.  Guersent,  with  the  same  view  of  conferring  the  desirable  pro- 
perties of  softness  and  elasticity  upon  collodion,  recommended  the 
addition  of  castor  oil  in  the  proportion  of  two  parts  to  thirty  of  the 
former. 

It  is  used  to  approximate  the  edges  of  wounds,  to  close  the  eyelids 
after  operations  upon  the  eyes,  and  as  a compressing  agent  in  discus- 
sing indolent  buboes  and  chronic  tumors. 

Mr.  Latour  has  proposed  the  following  formula  for  the  treatment  of 


STYPTIC  COLLOID. 


59 


superficial  inflammations:  Collodion,  46  grains ; Yenice  turpentine,  23 
grains;  castor  oil,  8 grains.  This  is  to  be  applied  over  the  whole  of 
the  diseased  surface.  His  theory  is,  that  tlie  contact  of  the  air  is  an 
indispensable  element  in  calorification,  and  he  seeks,  therefore,  to  shield 
the  inflamed  part  with  an  impenetrable  coating  of  three  or  four  lay- 
ers of  collodion,  put  on  with  a camel’s  hair  brush.  A similar  applica- 
tion is  also  used  with  great  success,  rarely  irritating  tlie  skin : Collo- 
dion, 30  parts ; old  castor  oil,  2 parts. 

Either  of  these  dressings  is  easily  detached  by  a linseed  poultice. 

M.  Arran,  observing  the  utility  of  the  salts  of  iron  in  erysipelas,  in 
order  to  facilitate  their  application,  combined  them  with  collodion, 
forming  a preparation  which  united  the  compressive  and  astringent 
effects.  It  consists  of  equal  parts  of  collodion  and  ethereal  tincture 
of  perchloride  of  iron.  It  is  more  supple  and  resisting  than  the  ordi- 
nary film  of  collodion,  and  adheres  more  tenaciously  than  it  to  the 
skin. 

M.  Yalette,  of  Lyons,  believes  it  to  be  a powerful  hemostatic,  and 
Mr.  J.  H.  Tucker  effectually  controlled  the  hemorrhage  from  leech- 
bites  with  it. 

The  mode  of  application  is  simple.  The  collodion  is  placed  upon  the 
skin,  previously  carefully  cleansed  and  dried,  with  a camel’s  hair 
brush ; or,  if  a firmer  bond  of  union  is  required  than  can  be  obtained 
by  the  collodial  film,  a piece  of  lint  or  a few  threads  of  charpie 
soaked  in  the  solution  may  be  laid  over  the  wound. 

Chloropercha  is  similar  in  its  properties  to  collodion,  and  is  pre- 
pared by  dissolving  gutta-percha  in  chloroform. 

Water-glass.  — Kiichenmeister  has  recently  introduced  to  the 
notice  of  the  profession  a new  adhesive  compound  which  he  states 
will  form  an  impermeable  film,  as  well  as  modify  the  vital  action  by 
virtue  of  its  alkalinity.  His  formula  is  the  following:  powdered 
quartz  15  parts ; caustic  potassa  10  parts ; charcoal  1 part.  Mix  and 
melt  them  together,  and  then  add  to  the  mixture  after  cooling  five 
pints  of  water,  and  boil  the  liquid  to  a syrupy  consistence,  when  it 
is  ready  for  use. 

Dr.  Miller,  as  a succedaneum  for  collodion,  proposes  a solution  of 
shellac  in  highly  rectified  alcohol  so  as  to  have  a gelatinous  consistence. 

An  agglutinative  may  be  extemporized  by  mixing  flour  and  white 
of  eggs  into  a paste,  and  spreading  this  upon  strips  of  muslin  or  linen. 

“Styptic  Colloid.” — Mr.  B.  W.  Richardson,  of  London,  has  recently 
called  attention  to  the  advantages  of  a compound  fluid  for  instant  and 
ready  use  in  dressing  wounded  surfaces,  which  he  has  designated  as 
“ styptic  colloid.” 

It  is  prepared  by  digesting  in  absolute  alcohol  for  several  days  the 
purest  tannin  that  can  be  obtained ; then  absolute  ether  is  added  until 
the  whole  of  the  thick  alcoholic  mixture  is  rendered  quite  fluid; 
xyloidine,  or  gun-cotton,  is  put  in  next  until  it  ceases  to  be  readily  dis- 
solved, and  to  confer  an  agreeable  odor  upon  the  mixture  a little 
tincture  of  benzoin  is  finally  added. 

The  solution  is  now  ready  for  use  and  can  be  applied  either  with  a 


60 


OF  THE  FIRST  PIECES  OF  DRESSING. 


"brush,  or  mixed  with  an  equal  quantity  of  ether ; it  can  be  used  in  the 
form  of  spray. 

The  “ styptic  colloid”  acts  by  the  tannin  in  its  composition  entering 
into  combination  with  the  albumen  of  the  blood  or  secretions  of  the 
wound  or  sore,  forming  an  impermeable  coating  upon  the  part  under 
which  the  healing  process  may  go  on  much  in  the  same  manner  as  it 
does  in  subcutaneous  wounds. 

As  to  the  mode  of  applying  the  fluid  it  is  sufficiently  simple;  sup- 
posing the  case  to  be  one  of  an  open  wound,  the  two  flaps  of  an 
amputation,  for  instance,  the  parts  should  be  brought  together  and 
sustained  by  four  or  five  fine  sutures.  In  a wineglass  tease  out  finely 
a little  cotton  wool  and  saturate  it  with  the  styptic  solution ; apply 
this  solution  with  a camel’s  hair  brush  over  the  surface  of  the  closed 
wound,  letting  it  lie  between  its  edges.  ISText  take  the  cotton  up 
with  a pair  of  forceps  and  lay  a seam  of  it  half  an  inch  wide  and 
the  eighth  of  an  inch  in  thickness  over  the  line  of  the  incision.  Upon 
this  another  layer  of  the  solution  is  put,  and  when  dry  cover  it  with  a 
little  dry  cotton,  and  finally  secure  the  whole  with  a roller  bandage. 

The  “ styptic  colloid”  may  be  used  as  a dressing  in  recent  wounds, 
hemorrhages,  ulcers,  cancerous  sores,  &c. 

“ In  no  case,”  observes  Mr.  Richardson,  "need  there  be  any  fear  that 
irritation  will  follow  the  application  of  the  solution,  on  the  contrary, 
the  action  of  it  is  so  purely  negative  that  it  might  be  considered  a 
sedative.  It  is  not  such  in  the  technical  sense  of  the  term,  but  it  so 
effectually  covers  the  wounded  and  susceptible  surfaces  as  to  maintain 
what  is  virtually  a sedative  influence:”  though  in  wounds  to  be  closed 
by  first  intention  it  is  not  good  to  leave  the  styptic  in  large  quantities 
between  their  margins,  as  it  sometimes  produces  friction  and  so  causes 
evolution  of  heat  and  pain. 

In  small  wounds  one  dressing  will  be  all  that  is  necessary,  and  the 
styptic  film  will  be  thrown  off  in  the  process  of  cure.  Even  in  larger 
wounds  it  will  be  advisable  to  leave  the  dressing  undisturbed  until 
the  parts  are  thoroughly  healed,  unless  for  some  urgent  reason. 

As  the  dressing  is  insoluble  in  water  either  hot  or  cold,  that  fluid 
should  not  be  employed  in  its  removal,  but  a mixture  of  alcohol  and 
ether,  or  equal  parts  of  absolute  alcohol  and  distilled  water,  warmed 
a little  above  the  temperature  of  the  body. 

Besides  this  simple  form  of  “ styptic  colloid”  this  fluid  combines 
well  with  other  medicinal  substances ; with  creasote  it  forms  a com- 
pound more  decidedly  antiseptic,  and  aids  in  solidifying  the  albumen 
more  thoroughly ; it  produces,  however,  some  degree  of  irritation.  The 
proportion  is  one  minim  of  creasote  to  two  drachms  of  the  solution. 

Carbolic  acid  acts  similarly  to  the  creasote,  and  may  be  combined 
in  the  proportion  of  five  grains  of  the  acid  to  two  drachms  of  the 
“ styptic  colloid.” 

Where  there  are  purulent  or  fetid  discharges  from  a surface  sur- 
rounded with  indurated  tissue,  iodine  may  be  added  with  decided 
advantage;  from  five  to  seven  grains  may  be  got  into  a quarter-ounce 
of  the  solution.  The  iodine  produces  no  irritation. 

The  compounds  of  iodine,  as  the  iodide  of  cadmium,  potassium  and 


THE  SURGICAL  WALLET. 


61 


ammonium,  the  bichloride  of  mercury  and  the  chloride  of  zinc  are 
also  taken  up  by  the  styptic  fluid. 

Morphia  and  the  other  narcotic  alkaloids  are  soluble  in  the  fluid, 
and  either  of  them  may  be  used  according  to  the  indications  presented. 

Two  to  four  grains  of  cantharidine,  dissolved  with  the  aid  of  a 
little  chloroform  in  a fluidounce  of  the  liquid,  will  furnish  an  epis- 
pastic  compound. 

The  Surgical  Tray. — For  convenience,  in  the  daily  routine  of 
duty,  the  surgeon  having  charge  of  the  surgical  service  of  a military  or 
civil  hospital,  generally  brings  together,  in  what  is  called  the  “ surgical 
tray,”  certain  instruments  and  dressings,  which  he  may  be  called  upon 
to  use  at  any  moment. 

The  one  employed  by  me  was  a simple  tray  2J  feet  long,  20  inches 
wide,  and  3 inches  deep,  divided  into  compartments  of  different  sizes, 
and  containing  a number  of  roller  bandages  of  various  lengths,  seve- 
ral kinds  of  compresses,  pieces  of  muslin  and  linen,  towels,  adhesive 
strips,  lint,  charpie  and  ligatures ; other  divisions  received  the  pocket 
case,  catheters,  bougies,  and  pin-cushion.  Three  cups  were  neatly 
fixed  in  one  end  for  holding  a small  quantity  of  whiskey,  turpentine, 
and  sweet  oil.  A quantity  of  fine  sponges  and  a bottle  of  camphora- 
ted tincture  of  soap  completed  the  supply.  A brass  hoop,  spanning 
the  tray  from  side  to  side,  served  the  purpose  of  a handle. 

The  Surgical  Wallet.— As  medical  officers  of  the  navy  were 
called  upon,  during  the  late  war,  occasionally  to  leave  their  ships  with 
boat  expeditions  on  the  coast,  or  up  the  narrow  rivers  of  the  South, 
it  became  necessary  to  have  certain  instruments  and  dressings  arranged 
in  a compact  form  for  transportation,  inasmuch  as  the  instruments 
allowed  to  ships-of-war  are  injudiciously  crowded  into  one  unwieldy 
case,  which  it  would  not  be  desirable  to  risk,  by  loss  of  the  boats,  or 
any  other  casualty,  and  thus  deprive  them,  perhaps,  of  every  surgical 
instrument  by  a single  unforeseen  accident. 

The  boats,  also,  on  such  occasions,  are  generally  crowded,  and,  there- 
fore, very  awkward  places  for  a heavy  and  bulky  surgical  case. 

Having  felt  the  need  of  such  an  arrangement,  I had  a surgical 
wallet  constructed,  consisting  of  a piece  of  strong  leather  three  feet 
long  and  fourteen  inches  wide,  folding  up  like  the  ordinary  pocket 
case,  and  containing  the  following  articles : two  pint-flasks,  with  screw 
caps  similar  to  the  pocket-flask,  the  one  containing  chloroform  and 
the  other  brandy ; a half  pint  flask  of  aqua  ammonia ; a square  block 
of  wood  excavated  upon  its  surface  to  receive  an  amputating  knife,  a 
small  saw,  and  a pair  of  bone  forceps,  one  movable  handle  answering 
for  the  former  instruments ; three  screws  and  six  field  tourniquets ; 
twelve  roller  bandages;  four  yards  of  muslin,  a lot  of  Maltese  crosses, 
and  other  compresses ; six  yards  of  adhesive  plaster ; twelve  short 
splints ; one  box  of  simple  cerate ; and  the  pocket-case.  When  the 
wallet  is  rolled  up,  a strap  is  hooked  to  both  of  its  ends,  by  which  it 
can  be  slung  over  the  shoulders  or  carried  in  the  hand. 

Every  ship-of-war  should  be  provided  with  such  a wallet,  ready  at 
any  moment  for  transportation,  should  the  surgeon  be  called  to  render 
assistance  at  a distance. 


62 


ON  THE  USE  OF  SOME  TOPICAL  REMEDIES. 


CHAPTER  III. 

ON  THE  USE  OF  SOME  TOPICAL  REMEDIES. 

The  remedies  now  to  be  described  are  applied  either  to  the  shin, 
or  to  the  mucous  membranes  continuous  with  it,  aud  lining  the 
entrances  of  the  several  interior  cavities. 

They  act  either  locally  upon  the  parts  to  which  they  are  applied,  or 
are  absorbed,  and  exert  an  influence  upon  the  economy  at  large.  In 
the  latter  instance,  the  remedy  may  either  be  brought  into  contact 
with  the  epidermis,  or,  this  being  removed,  with  the  dermis ; or,  again, 
with  the  cellular  tissue  beneath  the  skin,  by  hypodermic  injection. 

This  wide  range  of  application  of  these  topical  remedies  will  at 
once,  suggest  and  justly,  too,  that  they  are  both  numerous  and  capa- 
ble of  being  employed  in  a great  variety  of  forms  and  combinations; 
and  it  will  be  our  endeavor  in  this  place  to  consider  as  many  of  these 
as  are  in  daily  use  and  of  real  practical  value. 

Cerates. — “These  are  unctuous  substances,  consisting  of  oil  or 
lard  mixed  with  wax,  spermaceti,  or  resin,  to  which  various  medica- 
ments are  frequently  added.  Their  consistence,  which  is  intermediate 
between  that  of  ointments  and  of  plasters,  is  such  that  they  maj^  be 
spread  at  ordinary  temperatures  upon  linen,  by  means  of  a spatula, 
and  do  not  melt  or  run  when  applied  to  the  skin.”  ( U.  S.  D .) 

The  simple  cerate  of  the  Pharmacopoeia,  consisting  of  lard  and  white 
wax,  is  the  one  most  commonly  used  in  tbe  treatment  of  surgical  dis- 
eases, and  when  spread  upon  linen,  constitutes  what  is  known  under 
the  name  of  “the  simple  dressing.” 

When  applied  to  wounds,  it  should  be  smeared  sparingly  upon  the 
fringed  or  perforated  compresses,  for  too  much  will  convert  a very 
cleanly  dressing  into  a very  uncleanly  one;  the  fatty  matter  which  clings 
in  crusts  to  the  margins  of  the  sores  becoming  rancid  and  irritating. 

Should  charpie  or  lint  be  intended  to  act  as  absorbents,  a perfo- 
rated and  cerated  piece  of  linen  may  be  interposed  between  them  and 
the  secreting  surface,  for  these  materials  themselves,  covered  with 
greasy  matter,  are  but  indifferent  absorbents. 

If  it  is  desired  to  obtain  the  stimulating  effects  of  the  charpie,  as 
well  as  the  absorbent,  it  may  be  placed  in  direct  contact  with  the 
wound  which  has  its  edges  previously  protected  by  the  greased  fringed 
compress. 

Simple  cerate  is  sometimes  employed  with  frictions,  to  soften  the 
skin,  and  to  render  parts  more  supple,  in  such  cases  as  stiffened  joints, 
contracted  tendons,  and  rigidity  of  the  integuments. 

Its  bland  qualities  recommend  it,  when  spread  upon  soft  linen,  as  an 
application  to  surfaces  subjected  to  pressure,  or  excoriated.  Such 
cases  we  meet  with  in  patients  confined  for  a long  time  upon  their 


CERATES. 


63 


backs  in  consequence  of  fractures  of  the  bones  of  tbe  spine  and  lower 
extremities,  and  in  whom  the  shoulders,  buttocks,  and  sacrum  often 
become  extremely  tender. 

To  the  cerate,  opium,  belladonna,  iodine,  iodide  of  potassium,  or 
other  active  medicaments  are  occasionally  added  to  answer  special  in- 
dications. Combined  with  the  solution  of  the  subacetate  of  lead,  it  is 
much  used  in  the  treatment  of  burns  and  scalds,  and  the  ulcers  left 
by  blisters. 

The  cerate  thus  modified  by  these  combinations  may  be  applied, 
spread  upon  linen,  or  rubbed  into  the  part  with  the  hand,  the  latter 
plan  being  adopted  if  the  object  is  to  obtain  the  resolutions  of  chronic 
enlargements  of  the  joints,  or  of  glandular  swellings. 

Cerates  should  be  perfectly  bland  and  sweet;  by  long  keeping  they 
are  apt  to  become  rancid  and  extremely  irritating.  It  has  been  re- 
commended to  use  rancid  cerate  as  a dressing  for  flabby  granulating 
sores  needing  stimulation. 

The  following  formulae  for  extemporaneous  cerates  will  be  found 
useful  by  the  practitioner: — 

R. — Calamin®  pr®p.  5i>j  ; 

Camphor®  gr.  x ; 

Cerati  simplicis  §ij.  Misce. 

This  is  a mild  astringent  and  stimulant,  and  may  be  used  in  super- 
ficial ulcerations  produced  by  burns,  acrid  secretions,  chafing,  or  other 
causes. 

R. — Cerati  plumbi  snbacetatis, 

Cerati  simplicis,  aa  ^ss  ; 

Hydrarg.  chlo.  mit., 

Pulv.  opii,  aa  3j.  Misce. 

Used  in  excoriations,  ulcers,  burns,  scalds,  chilblains,  and  chancres. 
(Dr.  Parrish.) 

R. — Resin®  §j  ; 

Cer®  tlavae  Jij  ; 

Adipis  ^ij.  Misce. 

For  burns.  (Dr.  Physick.) 

R.— Hydrarg.  pr®cip.  albi  3'j ; 

Cerat.  simpl.  §j.  Misce. 

A valuable  application  in  venereal  ulcers,  porrigo,  and  other  cuta- 
neous diseases. 

R. — Hydrarg.  nitrico-oxidi  gj  ; 

Cerat.  simpl.  §j.  Misce. 

A common  application  to  ulcers  and  sores  in  general. 

R. — Unguenti  hydrarg.  nitr.  3j  ; 

Cerat.  simpl.  §ss.  Misce. 

A celebrated  application  to  the  edges  of  the  eyelids  in  chronic 
ophthalmia  and  opacities  of  the  cornea;  it  is  used  also  as  a dressing 
for  ulcers  and  sore  nipples. 

R. — Unguenti  hydrarg., 

Cerat.  saponis,  aa  £j  ; 

Camphor®  ^ij.  Misce. 

For  discussing  hardness  of  the  tissues  and  indurated  swellings,  and 
when  rubbed  along  the  course  of  the  urethra  relieves  chordee. 


64  ON  TIIE  USE  OF  SOME  TOPICAL  REMEDIES. 

R. — Cerati  resin*  comp,  (Deshler’s  salve) ; 

Adipis  3ij.  Misce. 

For  healing  ulcers  following  burns. 

R. — Cerae  alb*  ^iv  ; 

Olei  olivee  |j  ; 

Aceti  destillati  fijij.  Misce. 

Used  for  superficial  ulcerations  and  cutaneous  eruptions.  (Dr.  Ches- 
ton.) 

R. — Acid,  hydrocyanic,  gtt.  xx  ; 

Cerat.  simpl.  §ij.  M.  ft.  cerat. 

For  papular  eruptions  attended  with  itching.  (Dr.  Sargent.) 

R. — Creasoti  gtt.  xx  ; 

Cerati  simpl.  §ij  ; 

Zinci  oxidi  3j-  M.  ft.  cerat. 

For  scaly  eruptions.  (Dr.  Sargent.) 

Ointments. — “ These  are  fatty  substances,  softer  than  cerates,  of 
a consistence  like  that  of  butter,  and  such  that  they  may  be  readily 
applied  to  the  skin  by  inunction.”  ( U.  S.  D .) 

All  of  the  officinal  ointments,  with  the  exceptions  of  the  spermaceti 
and  simple  ointments,  are  combined  with  more  or  less  active  and 
irritating  medicaments.  Before  incorporating  these  with  the  fatty 
matter,  they  should  be  in  the  finest  state  of  subdivision. 

These  preparations,  like  cerates,  by  time  and  a high  temperature 
are  apt  to  undergo  chemical  change  and  become  rancid ; and  hence  it 
is  always  better  to  prepare  them  in  such  quantities  as  immediate  exi- 
gencies demand.  It  should  be  known,  however,  that  this  tendency  to 
rancidity  may  be  corrected  to  a considerable  degree  by  the  addition 
to  the  ointment  of  a small  quantity  of  benzoin,  poplar  buds,  or  slip- 
pery-elm  bark.  To  correct  the  fatty  odor  Dr.  Geisler  recommends 
ten  drops  of  nitric  ether  to  each  ounce  of  the  compound. 

The  simple  ointment  as  well  as  that  containing  spermaceti  is 
emollient,  and  serves  as  a mild  dressing  for  blistered  surfaces,  exco- 
riations from  whatever  causes,  and  wounds ; but  their  principal  use 
is  to  form  a basis  for  more  active  medicaments.  Of  these  we  may 
mention  the  unguentum  antimonii,  which  acts  as  a very  efficient  sup- 
purative counter-irritant  when  rubbed  upon  the  skin ; this  may  be 
done  twice  a day  or  oftener,  according  to  the  effect  produced.  The 
skin  should  be  unbroken,  as  the  contact  of  the  ointment  with  an 
excoriated  surface  sometimes  produces  an  unpleasant  degree  of  in- 
flammation, and,  in  rare  cases,  even  gangrene. 

The  strength  of  the  ointment  should  vary  according  to  the  sensi- 
bility of  the  skin  and  the  degree  of  effect  desired : the  officinal  pre- 
paration contains  two  drachms  of  the  tartar  emetic  to  an  ounce  of 
lard,  though  the  quantity  may  be  increased  to  three  drachms  when  a 
speedy  action  is  necessary.  The  eruptive  effects  of  this  drug  may  also 
be  obtained  by  sprinkling  a strong  solution  of  the  powder  upon  adhe- 
sive plaster  applied  to  the  skin. 

The  mezereon  and  elemi  ointments  are  also  irritant,  and  are  used 
as  stimulating  applications  to  sustain  the  discharge  from  a blistered 
surface,  issue,  or  seton,  and  in  obstinate,  ill-conditioned,  and  indolent 
ulcers.  The  ointment  of  Spanish  flies  is  used  for  the  same  purpose. 


OINTMENTS. 


65 


Creasote  ointment  lias  been  highly  extolled  as  a dressing  for  skin 
diseases,  and  especially  those  of  a scaly  character.  In  chilblains  it 
will  often  relieve  the  annoying  sense  of  heat  and  itching  like  a charm. 

Among  the  astringent  ointments  are  those  of  the  acetate  and  car- 
bonate of  lead,  forming  invaluable  dressings  in  burns,  inflamed  blisters, 
and  excoriated  surfaces. 

The  gall  ointments,  simple  and  compound,  are  now  chiefly  employed 
in  cases  of  inflamed  piles  and  prolapsus  ani. 

The  unguent  of  the  subacetate  of  copper  forms  a mild  escharotic 
in  fungous  granulations;  and,  diluted  with  lard,  is  a good  stimulant 
to  foul  and  flabby  ulcers,  scrofulous  ulcerations  of  the  edges  of  the 
eyelids,  chronic  otitis,  to  warts  and  corns,  and  to  several  forms  of 
cutaneous  eruptions. 

Mercurial  ointment  stands  at  the  head  of  the  alterative  class  of 
unguents,  and  is  regarded  as  a good  resolvent  of  indolent  buboes, 
chronic  glandular  enlargements,  and  certain  venereal  nodosities  of  the 
bones  and  soft  textures. 

To  affect  the  economy  to  the  extent  of  ptyalism,  it  is  used  by  inunc- 
tion, about  a drachm  of  the  ointment  being  rubbed  into  the  skin  upon 
the  inner  aspect  of  the  thighs,  legs,  or  arms,  morning  and  night,  until 
the  result  is  obtained. 

It  has  been  highly  extolled  for  preventing  the  pitting  of  the  pus- 
tules of  smallpox ; the  ointment  may  be  spread  upon  the  inner  surface 
of  a mask  made  of  leather  or  adhesive  plaster.  The  ammoniated 
mercurial  unguent  is  an  excellent  application  to  many  skin  diseases, 
as  itch,  herpes,  and  porrigo.  Ointments  containing  the  red  oxide,  the 
nitrate,  the  green,  and  red  iodides  of  mercury,  are  also  valuable  pre- 
parations in  dressing  scrofulous  ulcers,  indolent  sores  from  any  cause, 
chrouic  ophthalmias,  and  various  cuticular  affections,  and  especially 
porrigo  of  the  scalp. 

The  application  of  the  ointment  of  iodine  with  a camel’s  hair  brush, 
morning  and  night,  to  the  swollen  tonsils  after  the  disappearance  of 
inflammation,  will,  it  is  stated,  reduce  them  in  two  months. 

The  combination  of  iodine  and  iodide  of  potassium  is  frequently 
employed  in  the  form  of  an  ointment  to  resolve  goitrous  and  scrofu- 
lous tumors,  and  for  the  cure  of  certain  varieties  of  obstinate  skin  dis- 
eases. 

The  almost  specific  effects  of  those  preparations  containing  sulphur 
in  the  cure  of  itch,  crusta  lactea,  and  tinea  capitis  are  well  known. 
Ointments  of  white  hellebore,  tobacco,  tar,  pitch,  and  the  cocculus 
indicus,  may  be  also  had  recourse  to  as  a dressing  for  chronic  cuta- 
neous eruptions  with  great  advantage. 

The  most  frequently  employed  sedative  ointments  are  those  con- 
taining belladonna,  conium,  or  stramonium,  and  are  useful  in  many 
cases  of  irritable  or  painful  ulcers,  inflamed  piles,  and  skin  affections. 

In  using  any  of  the  above  compounds  containing  the  salts  of  lead, 
the  possibility  of  colica  pictonum  and  paralysis  occurring  should  be 
borne  in  mind.  We  should  also  carefully  guard  against  producing 
the  constitutional  effects  of  the  tobacco  and  the  white  hellebore  enter- 
ing into  the  composition  of  some  of  the  ointments. 

5 


66 


ON  THE  USE  OF  SOME  TOPICAL  REMEDIES. 


The  following  formulae  will  illustrate  some  of  the  usual  forms  of 
extemporaneous  ointments,  and  at  the  same  time  furnish  useful  com- 
binations for  the  treatment  of  various  surgical  diseases : — 

R. — Zinci  oxidi  5j  ! 

Adipis  §j.  Misce. 

An  astringent  application  in  common  use. 

R. — Morpliiae  acetat.  gr.  vj  ; 

Pulv.  gallarum  ; 

Unguent,  stramonii  Jj.  M.  ft.  unguent. 

For  hemorrhoids.  (Harlan.) 

R. — Tincturae  opii  f3j  ; 

Adipis  ^ij.  Misce. 

Used  in  painful  and  irritable  sores.  (Eicord.) 

R. — Plumbi  iodidi  ^ij  ; 

Adipis  5j.  Misce. 

This  is  very  useful  to  stimulate  an  indolent  or  fungous  venereal  sore. 
(Eicord.) 

R. — Potassae  earb.  ,^ss  ; 

Aquae  rosse  f§j ; 

Hydrarg.  sulpli.  rubr.  g ; 

01.  bergam.  fgss ; 

FI.  sulphuris, 

Adipis,  aagix.  M.  ft.  unguent. 

Aromatic  sulphur  ointment  for  itch.  (Bateman.) 

R. — Hyd.  subsulpbat.  Qss ; 

Unguent,  cetacei  gss.  M.  ft.  unguent. 

Ointment  for  skin  affections.  (Acton.) 

R. — Picis  liquid,  fgj  ; 

Butyri  salsi  gij  ; 

Liquefac.  una  dein  adde 
Potass,  irnpur.  ^j. 

Grafe’s  itch  ointment. 

R. — Chlorid.  hydrarg.  corros.  gr.  j ; 

Camphorae  pulv.  p)j ; 

Cerat.  simp.  gj.  Misce. 

This  is  very  useful  to  stimulate  an  indolent  or  fungous  venereal  sore. 
(Frestel.) 

R — Unguenti  hydrarg.  !jij  : 

Extracti  belladonnae  giij.  Misce. 

For  the  resolution  of  l}rmphatic  engorgements.  (Velpeau.) 

R. — Ammoniae  muriatis  Qiij  ; 

Unguenti  hydrarg.  mitis  5 iij.  Misce. 

Use  in  scrofulous  tumors,  traumatic  exostoses,  and  swellings  of  the 
bursae.  (Dupuytren.) 

R. — Hydrarg.  oxidi  rubr.  gr.  v; 

Cadmii  sulphat.  gr.  iv  ; 

Adipis  |ss.  Misce. 

Used  in  chronic  ophthalmia  and  nebulous  cornea.  (Sichel.) 

R. — Extracti  belladonnae  5'j  1 
Aquas  f^ij  ; 

Adipis  §ij.  Misce. 

Used  to  dilate  the  pupil,  and  the  os  uteri.  (Chaussier.) 


PLASTERS. 


67 


R — Unguenti  hydrarg.  fort.  §j  ; 

Antimonii  et  potass,  tart.  3j  ; 

Iodinii  gr.  x-xv.  Misce. 

For  chronic  glandular  tumors,  old  indurated  buboes,  &c.  (H.  John- 
son.) 

R. — Potassii  cyauidi  gr.  ij  ; 

Adipis  §ss.  Misce. 

An  excellent  application  for  pruritus  vulvre,  and  to  relieve  the  itch- 
ing of  cutaneous  eruptions. 

Plasters. — “These  are  solid  compounds  intended  for  external 
application,  adhesive  at  the  temperature  of  the  human  body,  and  of 
such  consistence  as  to  render  the  aid  of  heat  necessary  in  spreading 
them.  Most  of  these  have  as  their  basis  a compound  of  olive  oil  and 
litharge,  constituting  the  emplastrum  plumbi  of  the  U.  S.  Pharmaco- 
poeia.” ( U.  S.  D) 

In  the  preparation  of  plasters,  care  should  be  taken  not  to  employ 
any  degree  of  heat  that  would  alter  their  composition,  or  drive  off  any 
volatile  ingredient  upon  which  their  efficacy  may  depend.  As  the 
action  of  the  air  alters  the  color  and  consistence  of  plasters,  they  are 
usually  found  in  the  shops  in  cylindrical  rolls  carefully  wrapped  in 
paper. 

When  freshly  made,  the  plaster  can  be  easily  spread  with  a mode- 
rately heated  spatula,  and  it  remains  soft,  pliable,  and  adhesive. 

To  use  it  as  a dressing  the  material  is  thinly  spread  upon  leather 
or  linen ; the  former  being  generally  preferred  when  the  application 
is  to  be  made  upon  the  sound  skin,  and  the  latter  when  upon  exco- 
riated surfaces,  or  to  bring  the  edges  of  a wound  together.  The  fol- 
lowing is  an  excellent  plan  for  obtaining  a neat  plaster.  Take  a piece 
of  sheepskin,  or  some  textile  fabric  of  the  proper  size  and  shape,  place 
upon  its  margins  strips  of  adhesive  plaster  a half  inch  wide;  then, 
with  a gently  heated  spatula,  the  roll  of  plaster  is  melted  and  evenly 
spread.  When  the  strips  are  removed,  a clean  border  will  remain, 
which  will  prevent  the  patient’s  clothes  being  soiled,  and  at  the  same 
time  enable  the  dresser  to  seize  it  at  any  point  for  removal. 

All  plasters  are  more  or  less  irritating,  and  when  applied  to  the 
skin,  they  soften  it,  and  prevent  the  insensible  perspiration  from 
escaping,  thus  keeping  up  a continuous  local  bath,  to  which,  doubt- 
less, some  of  their  good  effects  are  attributable.  In  persons  with  very 
sensitive  skins,  the  irritation  they  occasion  is  sometimes  so  annoying 
as  to  preclude  their  use;  even  inflammation  and  erysipelas  have  been 
occasionally  observed  to  follow  their  emploj'rnent. 

As  gentle  excitants  in  chronic  articular  diseases,  scrofulous  tumors, 
and  indurations  of  the  tissues  from  various  causes,  plasters  of  Burgun- 
dy pitch,  of  iron,  of  galbanum,  and  of  ammoniac  often  serve  a good 
purpose. 

That  of  ammoniac  is  sometimes  combined  with  mercury,  and  re- 
sembles in  its  properties  somewhat  the  emplastrum  de  Vigo  cum  mer- 
curio,  so  frequently  employed  by  the  French  surgeons,  and  the  formula 
of  which  is : Lead  plaster  two  pounds  eight  ounces ; yellow  wax  two 
ounces;  resin  two  ounces;  bdellium,  olibanum  and  myrrh,  of  each  five 


68 


ON  THE  USE  OF  SOME  TOPICAL  REMEDIES. 


drachms;  saffron  two  drachms;  mercury  twelve  ounces;  turpentine  two 
ounces ; liquid  storax  six  ounces ; and  oil  of  lavender  two  drachms. 
Melt  the  plaster,  wax,  and  resin  together,  and  add  to  the  mixture  the 
other  materials.  The  plaster  may  be  spread  upon  leather  or  linen. 

No  dressing  has  been  more  highly  praised  than  this  as  an  applica- 
tion to  the  face,  to  prevent  the  pitting  of  the  pustules  of  smallpox ; 
it  is  used  in  the  same  manner  as  mercurial  ointment,  smeared  upon  the 
inner  surface  of  a mask.  As  a resolvent  and  stimulant  in  tumors  and 
ulcers  it  has  equally  as  much  reputation. 

The  emplastrum  plumbi  is  a cooling  and  sedative  dressing  well 
adapted  to  the  protection  of  excoriated  surfaces  and  small  wounds 
from  the  contact  of  the  air,  but  it  should  be  remembered  that  its  con- 
tinuous use  may  produce  lead  colic.  To  obviate  all  danger  from  this 
source,  it  has  been  suggested  to  supply  the  place  of  the  oxide  of  lead 
by  the  oxide  of  zinc,  which,  it  is  stated,  has  the  further  advantage  of 
exercising  a salutary  local  influence  upon  diseased  surfaces  by  dimin- 
ishing the  suppuration  and  facilitating  cicatrization. 

A preparation  composed  of  lead  plaster  and  soap  spread  upon  leather 
or  sheep-skin  is  an  admirable  application  to  bed-sores,  and  for  protect- 
ing the  various  bony  prominences  of  the  limbs  from  the  pressure  of 
splints. 

We  have  already  spoken  of  the  emplastrum  resinee,  or  adhesive 
plaster ; and,  therefore,  have  nothing  further  to  say  upon  the  subject 
under  this  head. 

The  following  are  formulas  for  extemporaneous  plasters: — 

R. — Saponis  gij  ; 

Emplastri  plumbi  Jss ; 

Ammon,  mur.  Jj. 

Melt  the  soap  and  lead  plaster  together,  and  when  nearly  cold,  add  sal  ammoniac 
in  fine  powder. 

This  plaster  stimulates  the  skin,  excites  the  action  of  the  absorbents, 
and  disperses  many  chronic  swellings  and  indurations.  (S.  Cooper.) 

R. — Gumrni  amnion.  §iij  ; 

Extracti  conii  3'j  ; 

Liq.  plumb,  acet.  f3 j . 

Dissolve  the  ammoniac  in  a little  vinegar  of  squills,  then  add  the  other  ingredients, 
and  boil  them  all  slowly  to  the  consistence  of  a plaster. 

Discutient.  (S.  Cooper.) 

R. — Cerse  flav.  £xiij  ; 

Terebinthiuse  5>>j  ; 

Cupri  subacetatis  Qij. 

Melt  the  yellow  wax  and  turpentine  together,  and  then  add  the.  salt  of  copper  in  a 
fine  state  of  subdivision. 

Used  to  remove  corns.  (Kennedy.) 

R. — Extracti  belladonnse  £x  ; 

Resinoe  elemi  56ss  1 

Cerse  alb.  5lss* 

Melt  the  resin  and  wax  together,  and  add  the  extract. 

A good  application  in  painful  tumors. 

Instead  of  the  belladonna,  the  extract  of  hyoscyamus,  stramonium, 
or  conium  may  be  used ; the  former  of  which  with  the  addition  of 


LINIMENTS. 


69 


fifteen  grains  of  gum  opium,  was  employed  by  Hufeland,  applied  to 
the  temples,  to  combat  insomnia.  Kicord  employed  opium  and  co- 
nium  in  syphilitic  pains  of  the  bones  and  joints. 

U. — Emplastri  conii  sjijss  ; 

Picis  Burgund.  5iss : 

Emplastri  plumbi  ^iss.  Misce. 

Spread  upon  a piece  of  leather  the  size  of  a dollar  piece,  and  sprinkle  over  its  sur- 
face ten  grains  of  tartar  emetic. 

Used  to  stimulate  indolent  buboes.  (Corsin.) 

Liniments  “ are  preparations  intended  for  external  use,  of  such  con- 
sistence as  to  render  them  conveniently  applicable  to  the  skin  by  gen- 
tle friction  with  the  hand.  They  are  usually  thicker  than  water,  but 
thinner  than  ointments,  and  are  always  liquid  at  the  temperature  of 
the  body.”  ( U.S.D .) 

They  are  commonly  applied  by  means  of  friction  with  the  hand  or  a 
piece  of  flannel,  though  it  is  sometimes  preferable  to  smear  them  upon 
cotton  or  linen,  and  lay  this  upon  the  diseased  or  injured  parts. 

Liniments  are  generally  stimulating  and  counter-irritant,  yet  we 
possess  in  the  linimentum  simplex  of  the  Pharmacopoeia  an  agreeable 
emollient  application  in  roughened  and  chapped  conditions  of  the 
skin,  and  in  the  linimentum  opii  an  anodyne  useful  in  sprains  and 
bruises  and  in  rheumatic  and  gouty  pains ; for  the  same  diseases,  the 
common  domestic  remedy  is  the  ordinary  hartshorn  liniment. 

In  recent  burns  and  scalds  an  elegant  and  efficient  dressing  will  be 
found  in  the  linimentum  calcis,  smeared  over  raw  cotton  and  then 
applied  to  the  surface;  this  is  also  called  Carron  oil,  from  having  been 
used  extensively  at  the  Carron  iron  works  in  Scotland. 

The  camphorated  soap  liniment,  or  opodeldoc,  is  an  excellent  article 
for  cleansing  and  hardening  parts  subject  to  pressure,  and  is  exceed- 
ingly refreshing  to  the  feelings  of  patients  confined  upon  their  backs 
with  fractured  lower  limbs.  In  these  cases  the  liniment  may  be  rubbed 
upon  the  skin  of  the  posterior  surface  of  the  body  with  a fine  sponge, 
and  then  wiped  off  with  a soft  towel. 

The  compound  ammoniacal  liniment  is  directed,  in  the  Pharmaco- 
poeia, to  be  prepared  of  two  strengths,  the  first  containing  § of  its  bulk 
of  strong  liquor  of  ammonia,  and  the  second  of  only  ; they  are  imi- 
tations of  Granville’s  counter-irritant  lotion,  and  are  equally  efficient. 

The  stronger  preparation  is  used  where  a speedy  counter-irritant 
effect  is  desired ; it  will  produce  rubefaction  in  from  two  to  eight 
minutes,  and  vesication  in  from  three  to  ten,  and  a caustic  effect  in  a 
somewhat  longer  period.  A convenient  method  of  applying  and  lim- 
iting its  action  is  to  saturate  a piece  of  lint  with  the  strong  solution, 
then  place  the  lint  in  the  lid  of  a pill-box,  and  lay  this  on  the  spot  we 
desire  to  vesicate. 

Other  forms  of  liniments  are  also  occasionally  used  : the  linimentum 
mruginis,  for  repressing  exuberant  granulations  and  to  stimulate  flabby 
and  ill-conditioned  ulcers;  the  camphor,  cantharidal,  and  turpentine 
liniments,  to  relieve  rheumatic  and  neuralgic  pains.  Dr.  Kentish  origi- 
nally proposed  the  turpentine  liniment  as  a remedy  in  burns  and  scalds. 
It  should  be  applied  as  soon  after  the  occurrence  of  the  accident  as 


70 


OX  THE  USE  OF  SOME  TOPICAL  REMEDIES. 


possible,  and  should  be  discontinued  when  the  peculiar  inflammation 
excited  by  the  fire  is  removed.  It  may  be  used  in  the  same  manner 
as  the  Carron  oil. 

Formulae  for  extemporaneous  liniments: — 

R. — Camphor*  giss  ; 

Chloroform  i fpj  ; 

Olei  olivae  f§ij.  Misce. 

Used  in  neuralgic  pains.  (Price.) 

R. — Olei  olivae  f§ij  ; 

Balsam.  Peru  3j  5 
Spermaceti  3U  5 
Cerae  alb.  gij  ; 

Acidi  hydroclilo.  fpj  ; 

Aquae  Pjvj.  Misce. 

An  excellent  stimulant  in  chilblains.  (Hospital  of  Saint  Antoine.) 

R. — Ammonia  carb.  3 ij  ; 

Alcohol  f3  i j ; 

Aquae  fi$x. 

Dissolve  the  carbonate  of  ammonia  in  water,  and  add  the  alcohol. 

Useful  in  ecchymosis  and  contusions.  (Swediaur.) 

R. — 01.  tiglii  f3ss  ; 

01.  cinnamomi  f5j  ; 

01.  olivae  f§j  ; 

Lin.  cantharid.  fjj . M.  ft.  liniment. 

For  neuralgia.  (Prof.  Jackson.) 

R. — Tinct.  opii  fjij  ; 

Sapouis  ,^ss  ; 

01.  olivae  5iv.  Misce. 

This  is  employed  at  the  Hotel  Dieu  for  its  anodyne  effects. 

R. — 01.  terebinth., 

01.  lini,  aa  Oss  ; 

01.  succini, 

01.  juniperi,  aa  f§iv  ; 

Petrol.  Barbadensis  ^iij  ; 

Petrol.  American.  §j.  Misce.  “ The  British  Oil.” 

Used  as  a stimulating  liniment. 

R. — Carbonis  sulphu.  f3j  ; 

Camphor*  ^ij ; 

Spts.  viu.  gal.  fgij  ; 

01.  olivae  fgiij . Misce. 

Used  in  chronic  articular  diseases.  (Wutzer.) 

R. — Extraeti  belladonnae  gr.  xv  ; 

Tinct.  opii  3j  ; 

01.  olivae  §j.  Misce. 

To  be  gently  rubbed  upon  the  temples  for  insomnia.  (Simon.) 

Glycerime. — When  pure,  glycerine  is  a thick,  syrupy  fluid,  unctu- 
ous to  the  touch,  without  odor,  colorless,  or  Avith  a slight  tinge  of 
yellow,  and  having  a very  SAveet  taste.  It  is  soluble  in  water  and 
alcohol  in  all  proportions,  but  insoluble  in  ether;  is  insusceptible  of 
rancidity,  and  does  not  undergo  spontaneous  change  of  composition 


GLYCERINE. 


71 


by  keeping  or  exposure.  Sekeele  discovered  it  in  1789,  and  Mr.  T. 
L>e  la  Rue,  of  London,  first  employed  it  surgically  in  1846. 

It  is  produced  extensively  as  a collateral  educt  in  the  manufacture 
of  candies.  According  to  the  formula  of  the  U.  S.  Pharmacopoeia, 
it  is  obtained  for  pharmaceutical  use  in  the  process  for  making  lead 
plaster;  though  the  purest  article  is  now  prepared  by  subjecting  fatty 
bodies  to  the  action  of  water,  at  a high  temperature  under  pressure. 

Its  properties  will  vary  according  to  the  process  employed  in  its 
manufacture ; when  free  from  all  impurities  it  is  a very  bland  and 
soothing  application;  while  on  the  other  hand,  the  presence  of  lime, 
chloride  of  calcium,  sulphuric  or  hydrochloric  acids,  the  most  com- 
mon foreign  matters  present  in  it,  will  confer  a more  or  less  irritating 
quality. 

Glycerine  has  been  used  internally  as  an  alterative  and  nutrient  in 
those  cases  in  which  cod-liver  oil  is  administered. 

As  a dressing  for  wounds  and  ulcers,  it  possesses  all  the  advantages 
of  simple  cerate,  protecting  their  surfaces,  and  preventing  the  pieces 
of  the  dressing  adhering  to  them,  with  the  additional  recommendation 
of  keeping  them  clean  and  moist.  We  speak  now  of  pure  glycerine, 
for  the  admixture  of  the  impurities  above  mentioned  will  render  it 
unfit  for  direct  application  to  recent  solutions  of  continuity. 

The  granulations,  under  the  dressing,  become  florid,  firm,  and 
healthy,  suppuration  gradually  diminishes,  and  cicatrization  is  pro- 
moted. 

The  glycerine  can  be  conveniently  applied  as  follows : Moisten  a 
perforated  compress  with  it,  which  is  to  be  placed  upon  the  wound ; 
over  this  lay  a gateau  of  charpie  dampened  with  water;  then  secure 
the  whole  with  a few  turns  of  a roller.  The  next  day  the  dressing 
may  be  removed  with  ease,  and  the  part  cleansed,  if  necessary,  with 
water  and  sponge. 

M.  Maisonneuve  employs,  as  a dressing  for  wounds,  compresses 
saturated  with  glycerine  either  pure  or  holding  in  solution  one-thou- 
sandth part  by  weight  of  carbolic  acid.  He  believes  the  glycerolate 
of  phenole  formed  in  the  above  mixture  a better  disinfectant  than  the 
permanganate  of  potassa. 

Mixed  with  the  materials  of  a poultice,  in  the  proportion  of  from 
one  to  three  drachms  or  more,  it  keeps  the  dressing  moist  and  soft  a 
long  time. 

As  an  excipient  it  is  also  a useful  article,  freely  dissolving  iodine, 
iodide  of  potassium,  morphia,  strychnia,  veratria,  atropia,  and  tannin. 

Glycerine  is  used  to  relieve  the  dryness,  occasioned  by  inflamma- 
tion of  the  lining  membranes  of  the  eyelids  and  external  auditory 
canal,  and  to  soften  concreted  cerumen ; as  an  emollient  in  pityriasis, 
lepra,  herpes,  and  other  skin  diseases;  and,  combined  with  borax,  as 
an  application  to  inflamed  and  ulcerated  conditions  of  the  throat  and 
pharynx. 

The  following  recipes  show  the  manner  in  which  it  may  be  com- 
bined with  other  drugs. 


72 


ON  THE  USE  OF  SOME  TOPICAL  EEMEDIES. 


R . — Gummi  tragaeantli.  gr.  xv  ; 

Aquae  oalcis  f§iv  ; 

Glycerin*  pur.  fgvij  ; 

Aqua  ros*  fjiij.  Misce. 

Used  in  superficial  burns,  excoriations,  impetigo,  and  chapped  lips. 
(Strati  n.) 

R. — Acidi  nit.  dil.  f§ss  ; 

Bismuth,  subnitratis  ^ss  ; 

Tinct.  digitalis  fgss  ; 

Glycerin*  pur.  I’3 vij  > 

Aquae  rosae  f§iv.  M. 

Used  as  a lotion  in  prurigo,  lichen,  lepra,  and  itching  of  the  skin. 

R. — Sodae  biboratis  5ss~5j  : 

Glycerin*  f3 vij  ; 

Aquae  rosarum  fjiv.  Misce. 

Used  for  sore  nipples,  chapped  lips,  irritation  of  the  skin  from 
shaving,  sunburn,  and  pityriasis. 

R. — Linimenti  saponis  camph.  fgij  ; 

Glycerinae  f5vij  ; 

Extracti  belladonnae  5j-  Misce. 

A good  application  for  sprains,  contusions,  and  gouty,  rheumatic, 
and  neuralgic  pains.  (Bouchardat.) 

Lotions.- — These  are  variously  medicated  fluids  applied  warm  or 
cold  to  diseased  parts  according  to  the  necessities  of  each  individual 
case;  they  are  always  extemporaneous  preparations,  and  hence  are 
exceedingly  numerous.  Their  therapeutical  effects  are  usually  astrin- 
gent, stimulant,  narcotic,  or  refrigerant ; and  the  formulae  below  are 
examples  of  these  different  classes. 

Astringent  lotions: — 

R. — Tannin  P)j  ; 

Spts.  vini  rect.  f.gss; 

Mist,  camph.  fljyj.  Misce. 

Used  for  spongy  gums. 

R. — Aluminis  5'j  ; 

Aquae  rosarum  f^viij.  Misce. 

An  injection  in  gonorrhoea,  conjunctivitis,  &c. 

R. — Gall  arum  cont.  5'j  ! 

Aquae  pur.  fgviij. 

Macerate  five  hours,  and  strain. 

The  liquid  may  be  employed  in  relaxed  conditions  of  the  mucous 
membranes  of  the  throat,  vagina,  and  rectum. 

R. — Zinci  sulpli.  5j  ; 

Aquae  pur.  fgviij.  Misce.  “The  White  Wash.” 

Employed  as  an  astringent  in  various  forms  of  inflammation. 

R. — Liquor  plumbi  subacetat., 

Spts.  vini,  aa  f 3 j ; 

Aqua  rosarum  Oj.  Misce. 

Used  in  chronic  inflammations. 

R. — Cupri  sulphat.  Qij  ; 

Puiv.  cinchonas  ,^ss; 

Aquae  fiuvialis  f^viij.  Misce. 

Used  in  syphilitic  ulcerations  of  the  throat.  (Physick.) 


LOTIONS. 


73 


R. — Ferri  et  potass,  tart.  3.1  1 
Aquae  j|j.  Misce. 

An  excellent  lotion  for  sloughing  sores. 

Stimulating  lotions : — 

R. — Hydrarg.  chlo.  mitis  pj  ; 

Aquae  calcis  fgviij.  Misce.  “ The  Black  Wash.” 

R. — Hydrarg.  chlo.  corros.  gr.  ij  ; 

Aquae  calcis  f^viij.  Misce.  “The  Yellow  Wash.” 

Both  of  these  lotions  are  much  used  as  a dressing  for  chancres, 
applied  with  a pellet  of  lint. 

R. — Acidi  clilorohydric.  gtt.  xv  ; 

Lactucarii  gss  ; 

Aquae  purae  f§vj.  Misce. 

Employed  as  a mouth-wash  in  excessive  ptyalism.  (Bicord.) 

R. — Ammoniae  mur.  gss  ; * 

Aceti, 

Spts.  vim,  aa  Oj.  Misce. 

As  a lotion  in  sprains,  bruises,  and  ecchymoses. 

R. — Ammoniae  mur.  3j  1 

Spts.  rosmarini  Oj.  Misce. 

Used  as  a discutient,  and  in  the  first  stage  of  “ milk  breast.” 
(Justamond.) 

R. — Sodae  biboratis  5j  ; 

Aquae  pur.  f giijss  ; 

Spts.  vini  f^-ss.  Misce. 

For  sore  nipples.  (Sir  A.  Cooper.) 

R. — Liquor  plumb,  subacet.  f§j  ; 

Tinct.  campli., 

Spts.  vini,  aa  f^ss.  Misce. 

As  a discutient  of  tumors  of  the  breast.  (Brodie.) 

Narcotic  lotions: — 

R. — Pulv.  opii,  ext.  conii,  ext.  belladon.,  vel  ext.  hyoscyami 
' Bj  ad  3ij  ; 

Aquae  ferventis  f§vj. 

Macerate  two  hours,  and  strain. 

Used  as  a dressing  for  painful  ulcerations. 

R. — Acidi  hydrocyan,  f 3 j ; 

Lactucarii  £j  ; 

Aquae  f|iv.  Misce. 

To  relieve  the  pain  of  cancerous  ulceration.  (Magendie.) 

R. — Plumbi  acet.  ^ij  ; 

Tinct.  opii  f§ss  ; 

Aquae  Oj.  Misce. 

Used  as  a lotion  to  sprains,  dislocations,  &c. 

R. — Vini  rubr.  f §ij  ; 

Tinct.  opii  fgj  ; 

Aquae  f §ij.  Misce. 

Apply  to  chancres  with  a pellet  of  lint.  (Bicord.) 

Refrigerant  lotions: — 

R. — Sodii  cliloridi, 

Potass,  nitratis, 

Ammoniae  mur.,  aa  §j  ; 

Aquae  Oij.  Misce. 


74 


ON  THE  USE  OP  SOME  TOPICAL  REMEDIES. 


R. — Ammoniae  mnr.  3j  ! 

Potass,  nitratis  5'j  ; 

Aeeti  f§j  ; 

Aquae  fgx.  Misce.  Sclimucker’s  Mixture. 

R. — TEtheris  sulphuric., 

Alcohol, 

Liquor  plumhi,  aa  f 5 j.  Misce.  (Sargent.) 

Collyria. — In  its  most  extended  meaning,  a collyrium  signifies 
any  remedy  applied  to  the  eye,  whatever  may  be  its  physical  con- 
dition, though  the  term  is  now  generally  used  as  a synonym  of  an 
eye-wash. 

Collyria  are  always  extemporaneous  formulae,  and  are  generally 
composed  of  astringent,  stimulating,  or  narcotic  drugs,  combined  in 
various  proportions;  the  mild  solutions  being  properly  eye-washes, 
while  the  more  active  receive  the  name  of  eye-drops. 

They  act  either  directly  upon  the  parts  to  which  they  are  applied, 
or  by  absorption.  In  the  former  case  their  action  is  generally  con- 
fined to  the  skin  and  mucous  membrane  of  the  eye  and  its  appendages, 
though  it  must  be  remarked  that  strongly  irritating  articles  produce 
congestion  of  its  deeper  structures.  Properly  managed,  they  are  ex- 
ceedingly neat  and  advantageous  therapeutical  means ; while,  on  the 
other  hand,  their  careless  or  improper  management  may  entail  irre- 
parable damage,  if  not  total  loss,  of  the  organ  of  vision. 

In  applying  an  eye-wash,  the  liquid  may  be  placed  in  a dish,  and 
soaked  up  with  a soft  linen  rag  or  sponge,  and  the  eye  washed  with 
it,  while  the  head  is  held  over  the  vessel.  When  the  secretion  is  very 
copious,  a syringe  charged  with  the  fluid,  and  its  beak  gently  insinu- 
ated beneath  the  lids,  without  pressing  the  ball  of  the  eye,  will  effect- 
ually clear  it  away. 

Eye-drops  are  to  be  instilled  into  the  eye  by  means  of  a quill,  glass- 
tube,  or  camel’s  hair  brush.  Another  way  is  to  seat  the  patient  in  a 
chair  with  his  head  thrown  back ; the  diseased  eye  being  closed,  place 
a few  drops  of  the  solution  in  its  inner  corner  ; then  move  the  lids  in 
opposite  directions  a few  times  until  the  collyrium  has  come  in  contact 
with  every  part  of  the  conjunctiva.  With  a little  elastic  bottle  and 
tube,  the  quantity  may  be  graduated  to  a nicety. 

Eye-salves  should  be  formed  of  finely-levigated  powders,  free  from 
all  grittiness,  combined  with  such  fatty  matters  as  will  readily  melt  by 
the  heat  of  the  eye. 

The  most  convenient  way  of  applying  them  is  to  take  a bit  of  the 
salve  the  size  of  a pin’s  head  upon  the  end  of  a probe,  and,  raising  the 
upper  lid,  place  it  beneath,  and  gently  rub  the  lid  upon  the  globe  of 
the  eye  for  a moment  or  so,  while  the  salve  is  melting,  to  diffuse  it 
over  the  conjunctiva. 

The  eyelids  may  also  be  everted  and  the  preparation  applied  with 
the  point  of  the  finger  or  a camel’s  hair  brush.  It  is  proper  to  remark 
that  in  all  cases  it  will  be  better  to  remove  all  scales  or  scabs  ad- 
hering to  the  margins  of  the  lids  by  the  preliminary  application  of 
glycerine. 

Eye  powders  should  be  very  fine  and  impalpable;  they  usually 
consist  of  some  metallic  oxide  in  combination  with  powdered  rock- 


COLLYRIA. 


75 


candy  as  a basis.  The  powder  may  be  brought  into  contact  with  the 
conjunctiva  either  by  taking  it  up  upon  the  point  of  a camel’s  hair 
brush,  or  by  placing  it  in  a quill,  and  with  a gentle  puff  of  the  breath 
projecting  it  into  the  eye. 

M.  Grariel  has  invented  an  ingenious  little  instrument  which  he  calls 
a pyxis,  for  this  purpose.  It  consists  of  a hollow  stem  connected  with 
a little  gutta-percha  bulb,  which  has  its  distal  hemisphere  enfolding 
with  the  proximal  one  in  such  a manner  as  to  form  a little  cup-shaped 
cavity,  into  which  the  powder  is  placed.  This  is  held  opposite  the 
eye,  and  the  surgeon,  placing  the  open  end  of  the  tube  in  his  mouth, 
by  a gentle  puff  forces  outward  the  enfolded  part  of  the  bulb  con- 
taining the  powder,  the  latter  impinging  upon  the  conjunctiva.  In- 
stead of  the  mouth,  he  sometimes  uses  a gum-elastic  ball  to  effect  the 
insufflation. 

These  powders  are  objectionable  on  account  of  the  pain  they 
produce.  All  the  good  results  likely  to  follow  their  application  can 
generally  be  obtained  by  their  solutions,  yet  in  cases  of  obstinate 
ophthalmias,  and  corneal  opacities,  their  use  is  still  recommended  by 
high  authority. 

Eye-vapors  have  almost  fallen  into  disuse;  they  are  stimulating, 
narcotic,  or  emollient,  according  to  the  nature  of  the  substance  from 
which  they  are  obtained.  The  application  is  sufficiently  simple — the 
patient  has  only  to  hold  the  diseased  eye  over  the  vessel  from  which 
the  vapor  issues. 

When  there  is  ulceration  of  the  cornea,  care  should  be  taken  in 
using  colly ria  containing  opium  and  the  salts  of  lead  and  silver  in  solu- 
tion ; for  by  double  decomposition  of  those  bodies,  there  results  a 
soluble  salt  of  morphia,  formed  by  the  acid  of  the  metal,  and  an 
insoluble  meconate  of  the  lead  or  silver,  whichever  is  present,  that 
fixes  itself  upon  the  ulcers,  and  forms  permanent  opacities. 

Strong  collyria  of  any  sort,  when  continued  for  a long  time,  produce 
chemical  change  and  discoloration  of  the  conjunctiva. 

The  salts  of  mercury,  copper,  zinc,  and  cadmium  will  produce  no 
deposition  with  opium.  The  application  of  eye-washes  may  be  made 
by  the  patient  or  his  attendants,  but  the  other  forms  of  collyria  should 
be  applied  by  the  practitioner  himself. 

For  the  purpose  of  expanding  and  contracting  the  iris,  two  active 
articles  of  the  materia  medica  are  used — belladonna  and  the  Calabar 
bean. 

To  produce  an  enlargement  of  the  pupil,  the  belladonna  in  the 
form  of  an  extract  thinned  a little  with  water,  an  ointment,  or  a solu- 
tion, is  applied  to  the  margins  of  the  orbit  pretty  freely ; the  result 
will  be  obtained,  if  the  article  is  good,  in  four  or  five  hours.  To  effect 
the  same  purpose  more  quickly  and  elegantly,  the  active  principle  of 
belladonna  (utropia),  dissolved  in  water  (gr.  ij-iv  ad  fsj),  is  now 
more  commonly  employed;  two  or  three  drops  of  this  placed  in  the 
eye  will  dilate  the  iris  fully  in  from  two  to  twenty  minutes.  Other 
forms,  recently  introduced,  are  atropized  paper  and  gelatine,  which  are 
prepared  by  incorporating  the  atropia  with  sheets  of  the  two  above- 
mentioned  articles,  and  then  dividing  them  into  little  square  pieces, 


76 


ON  THE  USE  OF  SOME  TOPICAL  REMEDIES. 


each  containing  about  JC)  of  a grain  of  atropia.  One  of  these  squares 
is  to  be  placed  beneath  the  lid. 

For  contracting  the  iris  the  Calabar  bean  is  used,  prepared  with 
thin  paper  or  gelatine,  like  atropia. 

The  following  are  examples  of  some  of  the  more  common  collyria : — 

Ip — Belladonnae  extracti  gss  ; 

Aquae  purae  f§viij. 

Solve  et  per  linteuru  cola. 

Sedative  eye-water  to  be  used  tepid.  (Jones.) 

I). — Hydrarg.  cyanidi  gr.  j ; 

Aquae  destillat.  fjiv.  Misce. 

Used  in  glandular  blepharitis  of  scrofulous  patients.  (Desmarres.) 

ip — Extracti  belladonnae  gr.  xx-xxx  ; 

Aquae  destillatae  f § j . 

Solve  et  per  linteum  cola. 

To  be  dropped  into  the  eye  for  dilating  the  pupil, 
ip — Atropiae  sulphat.  gr.  ij-iv  ; 

Aquae  destillatae  f§j.  Ft.  sol. 

For  the  same  purpose  as  the  preceding. 

ip — Tannin  gr.  xx; 

Aquae  pur.  §j.  Solve. 

To  be  dropped  into  the  eye. 

ip — Cupri  sulph.  gr.  j ; 

Tinct.  opii  gtt.  x ; 

Aquae  destillat.  f§ss.  Solve. 

Drop  into  the  eye. 

For  chronic  ophthalmia.  (Sichel.) 

ip — Zinci  sulph.  gr.  x ; 

Sodii  liydrochlor.  gr.  x ; 

Aquae  rosarum  fjjj.  Misce. 

To  be  dropped  into  the  eye. 

ip — Zinci  sulph., 

Sodii  liydrochlor. , aa  gj  ; 

Aquae  rosarum  fjviij.  Solve. 

An  eye-wash.  (Hartshorne.) 

ip — Lapidis  divini  gr.  xv  ; 

Aquae  rosarum  fgij.  Solve. 

To  be  dropped  into  the  eye  for  chronic  conjunctivitis.  (Bouehardat.) 

The  same  quantity  to  eight  ounces  of  rose-water  will  make  a good 
eye-wash. 

ip — Argenti  nitratis  gr.  v-x  ; 

Aquae  purae  f3j.  Solve. 

To  be  used  as  eye-drops  in  inflammatory  conditions  of  the  conjunctiva. 
I). — Hydrarg.  bichlor.  gr.  j ; 

Ammoniae  hydrochlorat.  gr.  x ; 

Aquae  rosarum  f§viij.  Solve. 

An  eye-wash. 

R. — Cadmii  sulph.  gr.  j ; 

Tinct.  opii  gtt.  x ; 

Aquae  destillat.  fj$ss.  Solve. 


Eye-drop.  (Sichel.) 


GAEGLES. 


77 


I). — Prsecipitati  alb.  gr.  xv  ; 

Tutise  pvsep., 

Boli  armen.  ppt.,  aa  3ss- 

Adipis  suilli  gj-Jij. 

M.  exactissime,  ft.  unguent,  opbtlial. 

James’  ointment. 

ip — Hyd.  oxidi  flay.  gr.  x-lx. 

Uug.  cetacei  §j.  M. 

An  admirable  application  in  conjunctivitis  and  phlyctenular  cor- 
neitis.  (Pagenstecher.) 

B_. — Argenti  nitratis  gr.  x ; 

Aquae  destillat.  q.  s.  ad  solvend.  uitrat.  ; 

Unguenti  cetacei  33. 

Prius  solvatum  nitras  ; dein  misceatur  accuratissime  solutio  cum  unguento. 

Used  in  chronic  and  acute  inflammations  of  the  conjunctiva.  (Jones.) 

ip — Oxidi  liydrarg.  rubri  bene  levigat.  gr.  iij-vj-xv  ; 

Axungise  praeparat.  Jij.  Misce  accuratissime  ft.  unguent,  oph. 

For  inflammation  of  the  eyelids,  and  ulcers  and  specks  of  the  cornea. 
(Jones.) 

ip — Acidi  tannic., 

Pulv.  saccb.  alb.,  aa  pp.  aeq.  Misce  et  tere  ut  ft.  puly.  subt. 

ip — Plumbi  acetatis  gr.  x ; 

Saccliari  alb.  gj.  Misce  et  tere,  etc. 

ip — Calomelanos, 

Saccliari  purif.,  aa  pp.  aeq.  Misce  tere,  etc. 

5.. — Oxidi  hydrarg.  rubri  gr.  x ; 

Saccbari  purif.  gj.  Misce  et  tere,  etc.  (Jones.) 

These  ophthalmic  powders  are  to  be  applied  to  the  eye  in  the  man- 
ner above  directed. 

Gakgles. — These  are  liquid  medicated  preparations  destined  to  act 
upon  the  mucous  membrane  of  the  mouth  and  pharynx.  Their  action 
is  exclusively  local,  as  they  remain  so  short  a time  in  contact  with 
the  parts  that  no  absorption  can  take  place,  and  therefore  no  remote 
effects  can  follow. 

The  quantity  directed  for  a gargle  may  be  six  or  eight  ounces, 
which  will  suffice  to  wash  out  the  throat  five  or  six  times  during  the 
day. 

In  the  act  of  gargling,  almost  all  the  muscles  of  the  neck,  larynx, 
and  pharynx  participate,  and  it  will,  therefore,  be  prudent  to  abstain 
from  the  use  of  these  preparations  in  severe  inflammatory  conditions 
of  the  throat,  as  it  is  probable  that  more  pain  will  be  inflicted  and 
more  injury  done  in  such  cases  than  can  be  counterbalanced  by  the 
advantage  derived  from  their  use.  Yet  even  in  these  instances  the 
gargle  may  be  available;  by  simply  taking  it  in  the  mouth,  and 
throwing  the  head  back,  the  fluid  will  be  carried  by  its  own  gravity 
over  the  diseased  surface,  where  it*  may  be  permitted  to  remain  a few 
moments. 

As  the  act  of  gargling  is  accomplished  by  the  voluntary  and  forci- 
ble emission  of  the  breath  through  the  liquid,  the  agitation  of  which 
gives  rise  to  the  peculiar  sound  from  which  the  name  is  derived,  this 
mode  of  medication  is  impossible  in  very  young  children. 


78 


ON  THE  USE  OP  SOME  TOPICAL  REMEDIES. 


Strong  solutions  and  the  powders  of  certain  drugs  may  be  conve- 
niently applied  to  the  throat  with  a camel’s  hair  brush  mounted  upon 
a long  handle,  or  a bent  probang,  or  even  the  index  finger : in  this 
manner  Bretonneau  has  availed  himself  of  the  action  of  powdered 
alum,  calomel,  and  other  medicaments  in  the  treatment  of  croup  and 
inflammatory  affections  of  the  throat.  The  therapeutical  effects  of 
gargles  are  generally  emollient,  astringent,  tonic,  or  detersive.  They 
are  the  objects  of  extemporaneous  prescription  of  which  the  following 
recipes  are  characteristic  examples: — 

g: . — /.cidi  chlorohyd.  f5ij  ; 

Mellis  f,5j  ; 

Decoct,  hordei  Oj.  Misce. 

Used  in  aphthous  ulcerations  of  the  mucous  membrane,  gangrenose 
. angina,  and  ptyalism.  (Ricord.) 

I£. — Ammoniae  hydrochlo.  3j  ; 

Mellis  ijiss  ; 

Aceti  £ij  ; 

Aquae  rosarum  §xij.  Misce. 

A good  detersive  and  stimulating  gargle  in  congestive  conditions 
of  the  mucous  membrane. 

— Aluminis  gj  ; 

Mellis  f§j  ; 

Aquae  rosarum  fjviij.  Misce. 

An  astringent  gargle. 

I^. — Sodae  biboratis  gij  ; 

Syrupi  gummi  acac.  f§j ; 

Decoct,  hordei  Ojss.  Misce. 

Employed  in  aphtha. 

fy. — Flydrarg.  bichlo.  gr.  ij  ; 

Mellis  f^ss  ; 

Aquae  destillat.  f^iv.  Misce. 

For  syphilitic  ulceration  of  the  throat. 

fy. — 01.  terebinthiuae  f§ss  ; 

Mucilag.  gummi  arab.  f^iv.  Misce. 

Used  to  control  excessive  salivation.  (Geddings.) 

I£. — Potass,  chloratis  5’j  ! 

Mellis  f§ss  ; 

Aquae  purae  fjiv.  Misce. 

For  the  same  purpose  as  the  above. 

IJ.. — Acidi  sulphurici  gtt.  xx  ; 

Mellis  gj  ; 

Decoct,  hordei  f^iv.  Misce. 

A detersive  gargle  in  gangrenous  inflammations  of  the  throat. 

I£  . — Sinapis  alb.  3 ss  ; 

Sodii  chlo.  3>ss  ; 

Aceti  f^ss  ; * 

Aquae  ferventis  fjviij.  Misce. 

Used  in  inflammatory  affections  of  the  throat.  (Fleury.) 

Collutories  are  certain  forms  of  remedial  agents  intended  for  appli- 
cation to  the  mucous  membrane  of  the  mouth.  Powdered  alum,  calo- 
mel, and  borax  are  occasionally  applied  with  a camel’s  hair  brush  to 
the  ulcerations  occurring  in  the  same  parts. 


POULTICES. 


79 


The  following  are  illustrative  forms  in  which  collutories  are  or- 
dered : — 

5. — Cincho.  rnbr.  pnlv., 

Carbo.  ligni  pulv., 

Irid.  flor.  pulv.,  aa,  gij.  Misce.  (Dunglison.) 

— Tinct.  myrrh,  f^ss  ; 

Tinct.  cincho.  fgj.  Misce. 

These  formulae  are  used  in  cases  of  sponginess  or  excrescences  of 
the  gums. 

iy — Calcis  chlorinat.  gr.  xx ; 

Mucilag.  acacise  fgj  ; 

Syrupi  fgss.  Misce. 

For  mercurial  sore  mouth. 

I}:. — Sod*  biboratis  gj  ; 

Mellis  fgj.  Misce. 

Used  for  aphthous  ulcerations. 

Poultices,  or  Cataplasms,  are  soft,  moist,  and  pap-like  substances, 
for  spreading  upon  muslin,  and  intended  for  external  application. 

When  they  act  by  virtue  of  their  warmth  and  moisture  only,  they 
are  called  simple  poultices,  while  the  addition  of  any  drug  confers 
the  name  of  medicated  or  compound  poultices  upon  them. 

Their  base,  or  excipient  as  it  is  called,  is  usually  some  farinaceous 
substance,  such  as  linseed  meal,  rice,  barley,  or  wheat  flour,  crumb 
of  bread,  sometimes  the  roots,  bulbs,  and  leaves  of  certain  plants, 
such  as  the  potato,  the  carrot,  onion,  marshmallow,  and  benne. 

The  vehicle  of  a simple  poultice  may  be  water  or  any  other  bland 
fluid,  and  this  charged  with  active  principles  before  being  mixed 
with  the  excipient  furnishes  cataplasms  with  qualities  as  varied  as 
the  principles  themselves. 

Various  animal  matters  have  been  employed  in  this  manner,  and  it 
need  scarcely  be  remarked  that  they  are  as  inefficient  as  they  are  dis- 
gusting. In  this  category  fall  those  poultices  made  of  the  common 
earth-worms,  snails,  and  the  various  parts  of  fre'shly-killed  animals. 
A chicken  or  other  fowl  split  in  halves,  that  the  warm,  steaming  flesh 
and  blood  may  come  in  contact  with  the  diseased  parts,  is  sometimes 
used  as  a popular  remedy  for  the  poisonous  bites  of  certain  animals, 
as  snakes  and  mad  dogs. 

In  the  preparation  of  a poultice  we  cannot  do  better  than  follow 
the  advice  of  Mr.  Abernethy,  who  studied  with  great  care  and  en- 
thusiasm this  form  of  surgical  dressing.  For  making  a bread  poultice 
he  says : “ Put  half  a pint  of  hot  wrater  into  a pint  basin ; add  to  this 
as  much  of  the  crumb  of  bread  as  the  water  will  cover;  then  place  a 
plate  over  the  basin,  and  let  it  remain  about  ten  minutes;  stir  the 
bread  about  in  the  water,  or,  if  necessary,  chop  it  a little  with  the 
edge  of  the  knife,  and  drain  off  the  water  by  holding  the  knife  on  the 
top  of  the  basin,  but  do  not  press  the  bread,  as  is  usually  done;  then 
take  it  out  lightly,  and  spread  it  about  one-third  of  an  inch  thick  on 
some  soft  linen  and  lay  it  upon  the  part.”  “When  thus  made,”  he 
rapturously  exclaims,  “Oh!  it  is  beautifully  smooth;  it  is  delightfully 
soft ; it  is  warm  and  comfortable  to  the  feelings  of  the  patient.” 

For  a linseed-meal  poultice  he  directs  you  to  “scald  your  basin  by 


80  ON  THE  USE  OF  SOME  TOPICAL  REMEDIES. 

pouring  a little  hot  water  into  it,  then  put  a small  quantity  of  finely- 
ground  linseed  meal  into  the  basin,  pour  a little  hot  water  on  it,  and 
stir  it  round  briskly  until  you  have  well  incorporated  them;  add  a 
little  more  meal  and  a little  more  water,  then  stir  it  again.  Do  not 
let  any  lumps  remain  in  the  basin,  but  stir  the  poultice  well,  and  do 
not  be  sparing  of  your  trouble.  If  properly  made,  it  is  so  well  worked 
together  that  you  might  throw  it  up  to  the  ceiling,  and  it  would  come 
down  again  without  falling  to  pieces ; it  is,  in  fact,  like  a pancake. 
What  you  do  next,  is  to  take  as  much  of  it  out  of  the  basin  as  you 
may  require,  lay  it  on  a piece  of  soft  linen,  let  it  be  about  a quarter 
of  an  inch  thick,  and  so  wide  that  it  may  cover  the  whole  of  the 
inflamed  part.” 

If  any  of  the  constituents  of  poultices  are  volatile,  the  degree  of  heat 
to  which  they  are  exposed  in  preparation  should  be  carefully  watched, 
that  their  chemical  integrity  may  not  suffer  change. 

A temperature  between  80°  and  90°  Fahr.  will  be  both  safe  and 
appropriate  for  an  emollient  poultice;  at  a few  degrees  above  this  ex- 
citant and  even  rubefacient  effects  follow. 

It  will  add  much  to  their  elegance  and  efficiency  first  to  make  a 
solution  in  water  of  any  remedial  agent  we  may  desire  to  use,  and 
then  incorporate  it  with  the  other  materials ; thus,  instead  of  employ- 
ing bruised,  or  chopped  vegetable  matters,  ive  use  their  decoctions  or 
infusions  ivhere  it  is  practicable. 

Cataplasms  may  be  applied  directly  to  the  skin,  or  have  interposed 
a piece  of  gauze,  tulle,  or  fine  open  textured  muslin.  The  first  plan 
is  generally  preferable,  as  the  pasty  consistence  of  the  poultice  permits 
an  accurate  contact  with  the  whole  extent  of  any  surface  however 
irregular,  and  it  ought  to  be  especially  adopted  when  there  is  present 
any  principle  intended  for  absorption.  The  interposition  of  a piece 
of  cloth  has  the  supposed  advantage  of  preventing  any  part  of  the 
poultice  sticking  to  the  skin,  or  flowing  beyond  the  limits  intended 
and  soiling  the  clothes  of  the  patient’s  bed.  But  when  the  cataplasm 
is  properly  made,  these  objections  do  not  exist,  and,  therefore,  the 
interposed  muslin  is  useless,  except,  perhaps,  when  the  applications 
are  destined  for  the  eye,  ear,  and  nostrils. 

It  should  also  be  observed  that  an  uncovered  poultice  is  more 
agreeable  to  the  feelings  of  a patient  than  one  provided  with  a cover- 
ing of  tulle  or  other  material.  The  warmth  and  moisture  of  a poul- 
tice may  be,  to  some  extent,  sustained  by  covering  it  with  a sheet  of 
oil  silk,  or  India-rubber. 

To  retain  the  dressing  in  its  proper  position,  we  use  the  many -tailed 
(Fig.  58),  or  roller  bandage,  or  that  of  Scultetus.  In  the  former  case 
the  limb  covered  with  the  poultice  is  placed  upon  the  centre  of  the 
bandage  spread  out  upon  the  bed,  or  a pillow ; then  commencing 
below,  the  strips  are  crossed  from  side  to  side  alternately.  Each  of 
them  ought  to  overlap  a third  or  half  its  predecessor,  and  be  suffi- 
ciently long  to  encircle  the  limb  once  and  a half. 

When  a strip  becomes  soiled  it  may  be  removed  and  another  sub- 
stituted for  it  without  disturbing  the  rest  of  the  bandage. 

A small  cataplasm  may  be  conveniently  retained,  by  crossing  over 


POULTICES. 


81 


it  narrow  strips  of  adhesive  plaster,  suffi- 
ciently long  to  extend  two  or  three  inches 
beyond  its  margins. 

The  removal  of  a poultice  is  neatly 
accomplished  by  seizing  it  by  one  of  its 
margins  and  gradually  reflecting  it  upon 
itself  until  it  is  entirely  detached  from  the 
skin.  Any  of  the  paste  adhering  to  the 
surface  may  be  dislodged  by  allowing  warm 
water  to  trickle  upon  it,  and  then  be  scraped 
off  with  the  spatula.  Should  it  be  too  hard 
to  be  removed  in  this  way,  the  application 
for  a few  minutes  of  a compress  wrung 
out  of  warm  water  will  soften  it  sufficiently 
to  admit  its  separation. 

Before  renewing  the  poultice,  the  surface 
should  be  carefully  cleansed  and  wiped  with 
a soft  towel. 

Cataplasms  by  their  warmth  and  humidity 
maintain  a constant  warm  bath  around  the 
parts  with  which  they  are  in  contact ; they 
soften  the  skin  and  facilitate  the  absorption 
of  any  medicament  which  may  be  incor- 
porated with  them.  In  order  to  obtain 
uniform  effects,  an  unvarying  temperature 
must  be  kept  up  by  changing  the  poultice 
every  two  or  three  hours,  or  even  more  fre- 
quently if  necessary.  Left  on  too  long,  its  moisture  escapes,  leaving 
behind  a dry,  hard,  and  irritating  mass,  the  albuminoid  constituents  of 
which  undergoing  chemical  changes  produce  a dough  at  once  uncon- 
genial to  the  feelings  of  the  patient  and  hurtful  to  the  surface  beneath. 
Medicated  poultices  should  be  changed  yet  more  frequently  than  the 
simple,  particularly  where  they  contain  elements  alterable  by  heat. 

The  long-continued  use  of  cataplasms  augments  the  sensibility 
of  the  tissues,  rendering  them  tender,  causes  debility,  and  in  the  case 
of  granulating  wounds  or  suppurating  buboes,  they  may  induce  such 
a degree  of  atonicity  as  to  arrest,  or  materially  interfere  with  the 
recuperative  efforts  of  nature ; erysipelas  and  even  gangrene  have 
sometimes  been  seen  to  follow  the  same  practice. 

A vesicular  or  pustular  eruption,  accompanied  with  excessive  itch- 
ing, has  been  noted  as  an  occasional  occurrence,  and  demands  the 
substitution  of  warm  water-dressings  for  the  poultice.  A grayish 
colored:  puffiness  also  not  unfrequently  follows  their  persevering  use 
upon  suppurating  surfaces. 

In  som'e  diseases  of  the  skin,  and  in  superficial  erysipelas,  warm 
poultices  are  sometimes  exceedingly  painful:  in  such  cases  water- 
dressings  will  answer  better  ; and,  indeed,  as  a general  rule  they  should 
always  be  chosen  when  a temperature  below  that  of  the  skin  is  desired 
to  be  maintained  in  a part. 

1st.  Emollient  poultices.  We  have  already  adverted  to  the  direc- 

6 


Fig.  58. 


Application  of  the  many-tailed  band- 
age for  retaining  cataplasms. 


82 


ON  THE  USE  OF  SOME  TOPICAL  REMEDIES. 


tions  given  by  that  astute  surgeon,  Mr.  Abernethy,  for  preparing  the 
common  bread  crumb  and  flaxseed  meal  poultices.  In  the  same 
manner  we  may  employ  other  materials,  such  as  bran,  corn-meal,  rice, 
wheat  or  barley  flour,  and  the  pulps  of  apples,  carrots,  or  onions  either 
raw  or  boiled.  The  vehicle  may  be  water,  milk,  or  other  bland  fluid. 

Emollient  cataplasms  were  formerly  much  employed  in  the  treat- 
ment of  recent  wounds ; but  this  practice  is  now  nearly  abandoned, 
the  more  elegant  water-dressing  usurping  their  place.  Often  in  in- 
flamed ulcers  great  relief  from  suffering  is  experienced  by  the  patient 
from  the  use  of  a linseed-meal  poultice. 

But  it  is  in  cases  of  inflammations  of  the  cellular  tissues,  or  phleg- 
mon, that  these  remedies  are  most  often  had  recourse  to ; they  favor 
maturation,  and  when  the  pus  is  discharged,  tend  to  dissipate  any 
remaining  engorgement  of  the  tissues. 

Deep-seated  inflammation,  as  of  an  interior  organ,  may  be  benefi- 
cially influenced  by  a large  warm  poultice  surrounding  the  chest  or 
abdomen.  For  the  same  purpose  a jacket,  made  of  oil  silk  or  India- 
rubber,  and  placed  next  to  the  skin,  will  also  be  found  advantageous ; it 
confines  the  insensible  perspiration,  and  thus  acts  in  the  manner  of  a 
poultice,  besides  protecting  the  skin  from  sudden  changes  of  tempera- 
ture ; it  is  also  lighter  than  a poultice. 

The  caution  should  always  be  taken  in  the  use  of  emollients  to 
stop  short  of  determining  any  hurtful  relaxation  of  the  skin  and  subja- 
cent cellular  tissue,  or  enfeeblement  of  granulating  wounds,  or  local 
capillary  congestion,  which  will  retard  the  plastic  process  and  subse- 
quent cicatrization.  We  should,  as  a general  rule,  abstain  from  them 
as  far  as  possible  in  passive  dropsies,  and  in  parts  disposed  to  gangrene. 

2d.  Stimulating  cataplasms  are  such  as  contain  some  stimulating 
drug  in  their  composition.  It  has  already  been  observed  that  the 
most  elegant  method  of  making  these  is  by  the  addition  of  an  infusion 
or  decoction  of  the  medicament  to  the  vehicle  before  it  is  mixed 
with  the  linseed  meal  or  bread  crumb,  yet  an  efficient  and  gently 
excitant  application  can  be  obtained  by  using  the  powdered  aromatic 
plants,  such  as  sage,  rosemary,  mint,  rue,  tansy,  and  wormwood,  in  the 
proportion  of  one  or  two  ounces  of  the  powder-to  the  materials  of  an 
ordinary  sized  cataplasm.  Some  practitioners  simply  soften  these 
herbs  in  warm  water,  and  inclose  them  between  two  pieces  of  muslin. 

Tansy  and  wormwood  have  been  used  as  anthelmintics  in  the  shape 
of  poultices  laid  over  the  abdomen,  and  may  be  regarded  as  useful 
adjuvants  to  more  active  internal  remedies.  In  cases  where  the  latter 
could  not  be  employed,  these  poultices  would  be  of  prime  importance. 

The  pulp  of  the  horseradish  root  and  the  rhizoma  of  the  Indian 
turnip  form  pretty  active  stimulating  poultices,  and  the  same  remark 
applies  to  several  of  the  indigenous  species  of  the  cruciferous  and 
ranunculous  plants  which  can  be  obtained  in  various  parts  of  the 
country,  and  used  instead  of  other  more  expensive,  or,  perhaps,  un- 
attainable articles. 

The  resins  in  tincture  or  powder  may  be  added  to  emollient 
poultices,  but  they  are  now  chiefly  employed  in  the  form  of  plasters. 

Chlorohydric,  nitric,  acetic,  and  oxalic  acids  are  excellent  local 


POULTICES. 


83 


stimulants,  the  three  former  in  the  proportion  of  one  to  two  drachms 
mixed  with  the  materials  of  a common-sized  cataplasm.  Velpeau 
has  derived  advantage  from  the  use  of  poultices  containing  slices  of 
lemon,  in  hospital  gangrene. 

Mustard  cataplasms  will  he  considered  in  the  section  on  rubefacients. 

Alcohol,  solutions  of  chlorinated  soda,  and  the  ammoniacal  salts, 
aromatic  tinctures,  and  that  of  camphor  will  form  useful  stimulating 
applications  added  to  a poultice  in  quantities  varying  from  one  to 
four  drachms. 

A poultice  made  with  yeast,  sour  beer,  or  porter  is  a favorite  remedy 
with  some  in  the  treatment  of  gangrene ; it  favors  the  separation  of  the 
sloughs,  and  is  a corrective  of  any  accompanying  fetor ; the  latter 
quality  depending  upon  the  antiseptic  property  of  the  carbonic  acid 
developed  during  the  fermentation  of  the  poultice. 

The  stimulating  poultices  are  used  to  promote  the  absorption  of 
the  effused  fluids,  in  contusions  and  sprains,  to  resolve  chronic  glandu- 
lar enlargements  and  other  tumors ; to  stimulate  the  granulations  of 
flabby  ulcers ; and  to  arrest  mortification,  or  when  the  tissues  are 
dead  or  sphacelated  to  hasten  their  separation. 

Those  containing  alcohol  and  the  volatile  oils  have  an  excitant 
action,  and  may  be  advantageously  employed  in  the  treatment  of  the 
chronic  inflammations  affecting  old  worn-out  persons. 

3d.  Astringent  poultices  are  commonly  made  of  powdered  cinchona, 
tormentilla,  bistort,  gall-nuts,  tan,  or  tannin.  These  powders  may  be 
mixed  with  the  paste  of  a flaxseed,  or  bread-crumb  poultice,  or  even 
employed  alone,  being  previously  converted  into  a plastic  mass  with 
water. 

The  astringent  metallic  salts,  such  as  the  sulphates  of  copper,  zinc 
and  iron,  alum,  the  acetate  of  lead  and  Goulard's  solution,  dissolved 
in  water,  answer  a better  purpose  than  the  preceding  articles,  in  cases 
where  very  powerful  astringent  and  resolvent  effects  are  desired. 

These  poultices  constringe  the  tissues  actively,  and  will  therefore 
be  found  useful  in  arresting  passive  hemorrhages  and  in  giving  tone 
to  relaxed  parts,  and  in  phagedenic  ulceration,  and  sloughing  buboes. 

I have  found  a light  poultice  containing  the  sulphate  of  iron  an 
admirable  remedy  in  certain  cases  of  erysipelas. 

It  has  been  recommended  to  apply  a poultice  containing  cinchona,  or 
a solution  of  quinine,  to  the  abdomen  of  children  suffering  with 
intermittent  fevers,  where  these  remedies  cannot  be  borne  by  the 
stomach. 

4th.  Narcotic  cataplasms  are  obtained  by  mixing  with  the  excipient 
a decoction  of  poppies,  the  watery  extract  of  opium,  or  the  extracts 
of  conium  and  belladonna.  The  late  Dr.  V.  Mott  recommended 
highly  a poultice  prepared  by  incorporating  the  fresh  leaves  of  the 
stramonium  plant  with  linseed  meal,  or  bread  previously  softened  in 
water.  The  leaves  themselves  sufficiently  moistened  may  also  be  used. 
Velpeau,  in  retention  of  urine,  sometimes  had  recourse  to  a poultice 
of  pellitory  applied  over  the  hypogastrium.  Mr.  North  applied 
moistened  tobacco  leaves  to  certain  cases  of  local  inflammation 
attended  with  spasms. 


84 


ON  THE  USE  OF  SOME  TOPICAL  REMEDIES. 


Besides  the  above  uses,  narcotic  poultices  are  employed  in  con- 
tusions, sprains,  and  in  rheumatic  and  neuralgic  pains,  and  colics. 

Mr.  Markwick,  of  London,  brought  forward  as  a substitute  for  emol- 
lient poultices  and  fomentations  a soft  porous  material  called  spongio- 
piline,  prepared  by  felting  together  sponge  and  wool,  and  afterwards 
rendering  one  side  of  the  sheet  impervious  by  coating  it  with  a layer 
of  India  rubber.  It  is  an  exceedingly  elegant  article,  but  too  ex- 
pensive for  general  use,  as  separate  pieces  would  be  needed  for  each 
particular  case.  The  fact  should  also  be  stated  that  spongio-piline  is 
not  near  so  agreeable  to  the  feelings  of  a patient  as  a well-made 
poultice.  The  same  piece  can  be  used  many  times  to  an  unbroken 
surface  without  any  danger ; but  in  suppurating  wounds,  it  absorbs  the 
pus,  from  which  it  is  very  difficult  to  cleanse  it.  The  best  manner  of 
doing  so  is  to  wash  the  spongio-piline  carefully  in  warm  water,  and 
then  in  a solution  of  the  chlorinated  soda;  lastly,  dry  it,  and  pass  a 
moderately  hot  flat-iron  over  its  surface,  taking  care  not  to  injure  the 
texture  of  the  material  by  the  heat.  Its  mode  of  application  is  simple, 
a piece  little  larger  than  the  surface  to  be  covered  is  cut  from  the 
sheet,  dipped  in  warm  water,  and  applied  with  its  unglazed  side  to 
the  skin. 

The  following  formulae  will  show  the  method  of  preparing  the 
different  kinds  of  poultices: — 

R. — Pulv.  lini  §vj  ; 

Aquse  ferventis  Ibiss.  Misce. 

The  best  emollient  poultice.  Any  other  farinaceous  substance  can 
be  used  instead  of  the  linseed  meal. 

R. — Rad.  carotse  recentis  Ibj. 

Bruise  in  a mortar,  or,  better,  grate  it  to  a pulp,  and  spread  on  muslin. 

“ Carrot  poultice  is  employed  as  an  application  to  ulcerated  cancers, 
scrofulous  sores  of  an  irritable  character,  and  various  inveterate  ma- 
lignant ulcers.”  (S.  Cooper.) 

R. — Farinas  ttj ; 

Cerevisias  fermenti, 

Aquas,  aa  f§v. 

Mix  the  yeast  with  the  water,  and  add  the  flour,  stirring  so  as  to  make  a cataplasm. 
( U.  S.  Dispensatory.) 

R . — Pulv.  carbonis  5ffi  1 
Micae  panis  5 i j ; 

Pulv.  lini  3x  ; 

Aquae  bullientis  f§x. 

“Macerate  the  bread  with  the  water  for  a little  while  near  the  fire  ; then  mix,  and 
gradually  add  the  flaxseed,  stirring  so  as  to  make  a soft  cataplasm.  With  this  mix 
two  drachms  of  the  charcoal,  and  sprinkle  the  rest  upon  the  surface.”  ( Pliarm . Loud.') 

This  is  an  excellent  application  to  fetid  and  gangrenous  ulcers,  and 
should  be  frequently  renewed. 

R. — Liquor  sod*  chlorinat.  f§ij  ; 

Pulv.  lini  ^iv  ; 

Aqu*  bullientis  fljvj. 

* “ Add  the  flaxseed  gradually  to  the  water,  constantly  stirring  ; then  mix  in  the 
chlorinated  soda.”  ( Pharm . Lond.) 

Used  to  diminish  scrofulous  tumors  and  glands,  and  as  a stimulating 
and  antiseptic  application  to  sloughing  and  other  fetid  ulcers. 


WATER  IN  SURGICAL  DISEASES  AND  INJURIES.  85 


R. — Aceti  fgj  ; 

Cataplasmatis  lini  Ibj.  Misce. 

Used  in  bruises  and  sprains.  The  mineral  acids  in  the  proportion 
of  from  one  to  two  drachms  may  be  added  to  a similar  quantity  of  a 
flaxseed  poultice. 

R. — Cataplasmatis  aluminis  q.  s. 

“ This  is  made  by  stirring  the  whites  of  two  eggs  with  a bit  of  alum,  till  they  are 
coagulated.  In  cases  of  chronic  and  purulent  ophthalmia,  it  has  been  applied  to  the 
eye,  between  two  bits  of  rag  ; and  it  has  been  praised  as  a good  application  to  chil- 
blains which  are  not  broken.”  (S.  Cooper.) 

R. — Ammonias  hydrochlor.  gss  ; 

Liquor  plumbi,  subacetatis  f5j  ; 

Cataplasmat.  lini  ^iv.  Misce.  (Ratier.) 

Employed  as  an  application  to  local  inflammations. 

R. — Extraeti  couii  ; 

Pulv.  lini  givss  ; 

Aquae  bullientis  f§x. 

“ To  the  water  gradually  add  the  flaxseed,  constantly  stirring,  so  as  to  make  a cata- 
plasm. Upon  this  spread  the  extract  previously  softened  with  water.”  ( Pharm . Lond .) 

Used  in  scrofulous,  cancerous,  syphilitic,  and  other  painful  ulcers. 

R. — Extraeti  opii  aquosi  f3j-f5'j 

Cataplasmat.  lini  Ibj.  Misce. 

A narcotic  poultice  may  also  be  obtained  by  simply  sprinkling  the 
surface  of  an  ordinary  poultice  with  the  tincture  of  opium. 


CHAPTER  IV. 

ON  TPIE  USE  OF  WATER  IN  SURGICAL  DISEASES  AND  INJURIES. 

The  employment  of  water  in  surgical  practice  is  an  important  sub- 
ject, and  demands  a careful  study  both  as  regards  its  local  as  well  as 
its  general  effects. 

Judiciously  managed,  the  surgeon  possesses  in  water  an  efficient 
remedy  for  the  relief  and  cure  of  a very  large  class  of  diseases  that 
habitually  come  within  the  sphere  of  his  observation.  It  is  at  once 
simple  and  effective,  always  at  hand,  and,  not  an  unimportant  con- 
sideration, it  costs  nothing;  so  that  the  indigent,  and  those  cut  off  by 
accident  or  necessity  from  communities  where  all  the  conveniences 
for  the  care  of  the  wounded  and  sick  are  present,  have  in  water  a 
precious  remedial  agent,  and  one  far  better,  in  a majority  of  cases, 
than  the  most  elaborate  surgical  dressings. 

Bathing  was  had  recourse  to  by  the  ancient  Greeks  and  Romans 
both  as  a cure  for  disease  and  as  a luxury;  and  the  extent  to  which 
they  indulged  in  it  is  shown  by  the  ruins  of  those  magnificent  struc- 
tures designed  by  them  for  this  purpose — one  of  them  being  described 
as  containing  six  thousand  separate  baths.  It  is  now  used  over  the 
known  world  for  this  twofold  object. 


86  WATER  IN  SURGICAL  DISEASES  AND  INJURIES. 

We  propose,  however,  in  this  place  to  consider  more  particularly 
the  use  of  water  as  a surgical  dressing,  and  afterwards  to  devote  a few 
pages  to  the  consideration  of  the  manner  of  employing  it  in  bathing. 

SECTION  I. 

WATER  AS  A SURGICAL  DRESSING. 

Water-dressings  are  either  cold,  warm,  or  medicated;  and  are 
adapted  under  various  conditions  of  temperature  and  medicinal  im- 
pregnation to  the  treatment  of  numerous  surgical  injuries. 

This  method,  as  a uniform  practice,  is  almost  peculiar  to  modern 
surgery,  our  predecessors  delighting  in  the  profuse  application  of 
salves,  plasters,  and  healing  balms,  and  swathing  sore  and  wounded 
parts  in  bundles  of  bandages,  and  various  other  dressings,  to  the  cer- 
tain detriment  of  their  patients. 

It  should  be  observed,  however,  that  Hippocrates  and  some  of  his 
successors  did  employ  both  hot  and  cold  water  in  their  practice,  but 
unfortunately  their  example  was  not  generally  followed  by  surgeons, 
and  it  was  not,  indeed,  before  the  sixteenth  century  that  attention  was 
again  drawn  to  the  subject. 

In  1553  the  quack  Doublet,  during  the  siege  of  Metz,  performed 
wonderful  cures  with  clear  water  from  the  fountains  and  wells,  aud 
the  celebrated  Pard  imitated  his  example. 

Still  later,  Percy,  Larrey,  Breschet,  Berard,  and  Velpeau,  both  wrote 
of  and  demonstrated  by  their  practice  the  superiority  of  water  over  the 
old  vulnerary  applications.  The  latter  surgeon  states  that  he  used  it 
extensively  with  signal  success  in  the  treatment  of  certain  fractures, 
phlegmonous  erysipelas,  burns,  and  in  various  wounds  from  contusing 
and  cutting  instruments ; after  operations  upon  the  eye,  in  amputation, 
and  a great  number  of  other  operations.  He  remarks,  in  regard  to 
its  advantages  and  disadvantages : “ If  it  is  true  that  cold  water-dress- 
ings employed  in  this  manner  during  the  hot  season  are  excellent 
topical  applications,  it  is  also  equally  true  that  in  cold  weather  it  is 
much  better  to  have  recourse  to  tepid  water;  so  also  is  it  true  that 
the  water,  whether  cold  or  tepid,  almost  always  wets  some  region  that 
we  would  have  wished  to  protect;  that  it  exposes  to  chills,  colds, 
rheumatisms,  inflammations  of  the  chest,  and  a great  number  of  affec- 
tions often  more  serious  than  the  disease  itself.  It  is  also  proper  to 
say  that  applied  indifferently  to  all  kinds  of  wounds,  it  may  produce 
as  much  evil  on  the  one  hand  as  good  on  the  other.  By  retarding 
the  circulation,  it  produces  gangrene  of  the  contused  or  divided 
tissues;  and  by  deranging  the  phenomena  of  inflammation,  it  fre- 
quently vitiates  the  suppuration,  and  rarely  admits  of  immediate 
adhesion  of  the  lips  of  the  wound.” 

In  England,  Liston  advocated  very  strongly  the  substitution  of 
water-dressings  for  poultices,  believing  them  to  possess  all  their  ad- 
vantages, with  the  additional  recommendation  of  greater  neatness  and 
cleanliness,  and  not  becoming  sour  or  injuring  the  sound  parts. 

Macartney  considers  that  they  act  differently ; aud  says  that  a 
water-dressing,  unlike  a poultice,  prevents  or  diminishes  the  secretion 


COLD  WATER-DRESSINGS. 


87 


of  pus,  checks  the  formation  of  exuberant  granulations,  and  removes 
all  pain. 

Kern,  of  Vienna,  and  Esmark,  of  Kiel,  were  the  supporters  and 
champions  of  the  practice  in  Germany. 

American  surgeons  have  generally  adopted  the  use  of  water  in  the 
treatment  of  wounds,  fractures,  and  local  inflammations. 

In  applying  water  care  should  be  taken  that  it  does  not  wet  the 
patient’s  clothes,  or  the  bed  ; this  can  be  easily  accomplished  by  means 
of  a sheet  of  India-rubber  or  oiled  silk,  placed  beneath  the  part  upon 
which  the  dressing  is  applied. 

Cold  Water-dressings  are  most  frequently  employed  in  the  treat- 
ment of  superficial  inflammations,  fractures,  gunshot  wounds,  and 
inflammatory  engorgements. 

The  action  of  the  cold  is  to  reduce  the  volume  and  temperature  of 
the  parts  to  which  it  is  applied,  to  constringe  the  muscular  fibres, 
both  through  the  purely  physical  effect  of  condensation,  and  by  vital 
contractility,  and  thereby  diminishing  the  calibre  of  the  blood- 
vessels and  the  volume  of  blood  circulating  through  them  as  well  as 
its  rapidity.  The  chemical  and  vital  forces  constantly  taking  place 
in  the  living  tissues  are  also  retarded. 

The  water  should  not  be  so  cold  as  to  produce  shivering,  or  other 
disagreeable  sensations,  and  the  dressing  should  not  consist  of  more 
than  a simple  fold  of  soft  linen  or  lint,  and  it  is  also  important  to  leave 
it  exposed  to  the  air  that  continual  evaporation  may  take  place,  else 
the  heat  of  the  parts  will  soon  raise  the  temperature  of  the  cloths  and 
thus  defeat  the  objects  in  view,  and  instead  of  obtaining  the  thera- 
peutical effects  of  cold,  we  shall  have  those  of  a fomentation,  which 
are  quite  different. 

When  the  linen  is  simply  wrung  out  of  water  it  will  require  fre- 
quent changing,  in  order  to  keep  down  the  temperature.  A piece  of 
ice,  of  sufficient  size  to  be  easily  borne  by  the  part,  may  be  placed 
upon  the  dressing,  and  its  frequent  removal  will  thereby  be  avoided. 
I prefer,  however,  an  arrangement  whereby  a constant  supply  of  cold 


Fig.  59. 


Apparatus  for  cold  water-dressing. 


water  can  be  obtained  from  a cup  with  a few  small  holes  perforating 
its  bottom,  and  lightly  closed  with  a few  filaments  of  charpie  so  that 


88  WATER  IN  SURGICAL  DISEASES  AND  INJURIES. 


the  fluid  issues  in  drops.  A cotton  wick  with  one  end  immersed  in 
the  water  in  the  vessel  and  the  other  resting  upon  the  muslin  to  be 
wetted  will  answer  the  same  purpose,  as  is  seen  in  Fig.  59.  This  simple 
plan  can  be  pursued  anywhere,  and  requires  little  surveillance. 

I have  derived  benefit  from  water-strapping  in  ulcers  and  certain 
forms  of  inveterate  skin  diseases,  sucb  as  eczema  of  the  lower  ex- 
tremities. Strips  of  muslin  or  linen  are  taken  and  soaked  in  cold 
water  until  they  are  thoroughly  saturated,  and  they  are  then  applied 
in  the  same  manner  as  Baynton’s  dressing  already  described. 

When  a powerful  and  sudden  impression  of  cold  is  sought  for,  as  in 
strangulated  hernia,  some  surgeons  apply  a thin  slice  of  sponge  satu- 
rated with  ether. 

M.  Jobert,  Surgeon  to  the  Hopital  St.  Louis,  Professor  Miller,  and 
Mr.  Earle  were  strongly  in  favor  of  treating  burns  with  iced  water, 
by  covering  the  burnt  parts  with  pledgets  of  lint  dipped  in  that  fluid, 
or  with  bladders  of  ice,  and  continued  not  for  minutes,  but  for  hours. 
Of  course,  in  extensive  burns  attended  with  depression,  this  method 
Would  be  inapplicable  from  the  sedative  effects  of  the  cold  applied  to 
so  large  an  extent  of  surface. 

Warm  Water-dressings,  or  fomentations,  are  much  more  easily 
managed  than  cold ; the  temperature  of  the  water  should  be  such  that 
the  patient  experiences  agreeable  sensations  from  its  use.  It  may  be 
applied  by  means  of  a piece  of  soft  muslin  folded,  or,  what  is  better, 
a piece  of  flannel.  To  prevent  evaporation  and  consequent  cooling, 
a piece  of  oiled  silk  large  enough  to  more  than  cover  the  muslin  may 
be  laid  over  the  dressing,  and  the  whole  secured,  if  necessarjr,  with  a 
few  turns  of  a narrow  roller. 

When  the  inflammation  and  the  discharge  of  pus  are  moderate,  the 
linen  need  not  be  disturbed  more  than  three  or  four  times  a day,  care 
being  always  taken  to  have  a fresh  piece  of  cloth  ready  the  moment 
the  previous  one  is  removed,  that  no  sudden  changes  of  temperature 
may  happen  to  the  part.  It  will  also  be  advantageous  to  abandon 
the  use  of  the  warm  water-dressings  gradually. 

Amussat,  in  order  to  do  away,  as  much  as  possible,  with  these 
sudden  alterations  of  temperature,  and  also  to  economize  the  time  of 
the  attendants,  an  important  object  in  large  hospitals,  recommended 
for  these  purposes  the  following  dressing : Place  over  the  diseased 
surface  a piece  of  tulle  or  muslin,  perforated  with  numerous  holes  to 
permit  the  free  escape  of  pus,  which  is  to  be  absorbed  by  a layer  of 
soft  old  muslin  wrung  out  of  warm  water  and  laid  over  the  tulle: 
this  he  calls  the  absorbent.  The  third  layer,  denominated  the  humec- 
tant,  consists  of  a fine,  thin,  and  porous  sheet  of  amadou,  also  soaked 
in  warm  water,  which  it  readily  yields  up  to  the  muslin : and  lastly, 
to  prevent  evaporation,  oiled  silk  is  laid  over  the  whole.  This  dressing 
requires  to  be  renewed  but  once  every  ten  or  twelve  hours;  it  permits 
the  matter  to  escape  freely,  sustains  the  moisture,  and  keeps  up  a 
uniform  temperature  in  the  parts. 

Warm  applications  are  extremely  soothing  in  inflammatory  affec- 
tions, accompanied  with  undue  sensibility,  pain,  or  soreness;  they 
relax  the  tissues  and  promote  the  secretions  and  excretions ; and  in 


IMMERSION. 


89 


this  respect  are  often  efficient  galactagogues.  "When  colcl  water  is 
disagreeable  to  the  feelings  of  the  patient  in  the  treatment  of  fractures, 
gunshot  wounds,  and  other  injuries,  warm  water  may  often  be  substi- 
tuted for  it  with  advantage.  This  dressing  has  been  highly  lauded 
in  burns  and  scalds,  where  it  is  said  to  exercise  a beneficial  influence 
in  mitigating  the  consecutive  inflammation,  rendering  the  consequences 
less  severe  locally,  and  the  recuperative  process  more  speedy  than 
under  other  modes  of  treatment. 

Mr.  Phillips  has  found  the  most  intractable  cases  of  eczema  to  yield 
to  this  mode  of  treatment  in  four  weeks. 

Medicated  AVater-dressings. — Warm  and  cold  water,  chiefly 
the  former,  are  sometimes  combined  with  emollient,  anodyne,  astring- 
ent, and  deodorant  substances.  The  emollients  enhance  its  soothing 
effects  and  confer  the  additional  advantage  of  not  requiring  the 
dressings  to  be  changed  so  frequently. 

The  watery  extract  of  opium,  laudanum,  the  extract  of  belladonna, 
and  other  narcotics,  increase  the  power  of  control  of  warm  water  over 
exaggerated  sensibility  of  parts  and  excessive  pain. 

In  applying  warm  dressings  to  portions  of  the  body  affected  with 
disease  or  injury,  and  disposed  to  hemorrhage,  or  discharging  pus  in- 
ordinately, the  addition  of  the  sulphates  of  zinc  and  copper,  and  the 
acetate  of  lead  to  the  water  will  be  advantageous.  The  solutions  of 

O 

the  permanganate  of  potassa  and  the  alkaline  chlorides,  tar  water,  and 
creasote,  may  be  employed  in  like  manner  for  correcting  the  fetor  of 
suppurating  and  sloughing  sores  and  wounds. 

Dry  Fomentation  is  a name  applied  to  the  act  of  raising  the 
temperature  of  parts  of  the  body  by  the  application  of  heated  objects 
to  them,  such  as  billets  of  wood,  bags  of  bran,  chamomile,  hops,  &c. ; 
bottles  filled  with  hot  water,  and  bricks  heated  and  wrapped  in  nap- 
kins. The  object  in  view  being  to  stimulate  the  vital  powers  depressed 
by  the  shock  of  severe  injury,  either  accidental,  or  the  result  of  a surgi- 
cal operation.  In  such  cases,  a blanket  wrung  out  of  hot  water  and 
wrapped  around  the  patient’s  body,  will  also  be  found  a useful  means. 

It  should  not  be  forgotten,  however,  that  where  there  is  insensibility 
of  the  skin,  paralysis,  or  concussion  of  the  nervous  system,  the  utmost 
caution  must  be  taken  that  the  temperature  of  these  bodies  be  not  too 
high,  as  the  patient,  from  defective  sensation,  may  be  unable  to  give 
the  practitioner  warning  of  the  presence  of  a destructive  heat  in  con- 
tact with  his  person,  and  therefore  a greater  or  less  extent  of  the  skin 
may  be  destroyed  before  it  is  discovered. 

Bottles  filled  with  hot  water  should  be  carefully  corked  that  no 
leakage  occur  and  wet  the  bedclothes. 

Immersion. — Another  mode  of  availing  ourselves  of  the  beneficial 
action  of  water  in  the  treatment  of  wounds  is  by  immersion.  It  has 
advantages  in  certain  cases,  and  deserves  our  consideration. 

Percy  remarks  that  in  external  diseases  where  the  local  heat  is  so 
exalted  that  it  dries  in  a very  few  moments  the  thickest  compress 
soaked  in  water,  nothing  would  succeed  better  in  restraining  the 
violence  of  vital  activity,  and  in  restoring  calmness  and  regularity  to 
the  organism,  than  plunging  the  part  into  a bath.  Later,  Langenbeck, 


90  WATER  IN  SURGICAL  DISEASES  AND  INJURIES. 


of  Berlin,  used  it  with  the  happiest  results  in  lacerated  and  contused 
wounds,  and  after  surgical  operations  performed  upon  various  parts 
of  the  body.  In  ordinary  cases  he  kept  the  temperature  of  the  water 
at  about  70°  Fahr.,  and  never  exceeded  86°;  where  the  inflammatory 
reaction  was  greater  it  was  reduced  to  50°.  Baudens  extolled  a bath 
at  32°,  a temperature  at  which  he  most  frequently  employed  water. 

It  can  readily  be  imagined  that  there  will  be  some  little  difficulty 
in  the  localization  of  baths  in  the  continuity  of  the  limbs,  but  as  immer- 
sion is  especially  adapted  to  the  treatment  of  inflammatory  diseases 
of  the  fibrous  structures  of  the  hands  and  feet,  and  of  burns,  a common 
tub  will  be  all  that  is  required.  This  should  be  sufficiently  large  to 
hold  such  a volume  of  water  that  the  heat  of  the  part  immersed  will 
not  elevate  its  temperature  for  some  time ; perhaps  three  or  four  times 
a day  the  water  will  need  renewal. 

On  the  other  hand,  when  the  disease  is  located  at  some  intermediate 
part  of  the  extremities,  we  will  say  at  the  knee,  for  instance,  a special 
contrivance  will  be  required ; and  the  one  with  which  I have  made 
my  experiments  answers  very  well.  It  consists  of  a wooden  trough 
thirteen  inches  wide,  eighteen  long,  and  twelve  deep,  with  a sheet  of 
India-rubber  ten  inches  wide  tacked  to  each  end,  and  having  at  their 
unattached  borders,  or  free  margins,  elastic  cords  which  closely  en- 
circle the  limb,  above  and  below,  to  prevent  the  egress  of  the  water; 
a glass  plate  may  be  laid  over  the  trough  at  the  option  of  the  surgeon. 
To  supply  the  apparatus  with  water  of  a uniform  temperature,  a 
reservoir — a keg  or  bucket  will  do — is  placed  near  to  and  above  the 
level  of  the  bed,  and  connected  with  one  of  the  upper  corners  of  the 
trough  by  an  India-rubber  tube;  the  corner  diagonally  opposite  this 
is  fitted  with  another  tube  to  carry  off  the  water  and  discharges  from 
the  wound  into  a basin  resting  upon  the  floor. 

When  the  limb  is  placed  in  the  trough,  the  latter  should  be 
arranged  a little  lower  than  the  plane  of  the  body  and  somewhat 
inclined,  so  that  the  pus  will  settle  towards  its  outer  and  lower  corner, 
where  the  aperture  of  egress  is  placed.  If  the  stump  of  an  amputated 
limb  is  to  be  immersed,  but  one  of  these  India-rubber  sheets  is  unneces- 
sary, inasmuch  as  the  box  should  then  have  four  sides  instead  of  three, 
as  in  the  former  case. 

The  only  dressings  that  need  be  applied  in  the  case  of  wounds  and 
stumps  are  a few  points  of  suture  and  a few  turns  of  a roller. 

In  this  manner  may  be  treated  the  inflammations  of  the  tendinous 
sheaths,  and  fibrous  tissues  of  the  palms  of  the  hands  and  soles  of  the 
feet,  contused  and  lacerated  wounds,  amputated  limbs,  and  injuries  of 
the  joints. 

My  experience  with  immersion  has  been  limited  to  the  two  latter 
class  of  cases,  and  the  results  have  been  gratifying. 

Irrigations. — Irrigation  is  a method  of  applying  water  by  per- 
mitting gentle  currents  to  flow  continuously  over  any  portion  of  the 
body.  It  is  of  considerable  antiquity,  and  the  experience  of  surgeons 
all  over  the  world  attests  to  its  great  value  as  a therapeutical  remedy 
in  inflammations. 

Various  kiuds  of  apparatus  have  from  time  to  time  been  suggested 


IRRIGATIONS. 


91 


to  effect  irrigation,  but  one  of  the  simplest,  and  at  the  same  time  as 
efficient  as  any  other,  however  complicated,  consists  of  a common  tin 
pot  or  wooden  bucket,  with  its  bottom  perforated  with  a few  holes, 
through  which  pieces  of  common  wick  are  thrust,  so  as  to  permit  the 
water  to  run  in  a fine  stream.  The  bucket  should  be  affixed  by  a cord 
to  the  ceiling  or  to  a hoop  spanning  the  patient’s  bed. 

The  apparatus  (Fig.  60)  used  by  Yelpeau  at  La  Charitd  consists 
of  a reservoir  with  a tube  projecting  downwards  from  its  bottom,  and 


Fi  . 60. 


crossed  at  right  angles  by  another  tube,  furnished  with  a number  of 
hollow  stems  placed  at  equal  distances  upon  its  length.  The  supply 
of  water  is  regulated  by  a stopcock  upon  the  vertical  tube,  and  it  flows 
out  in  a number  of  slender  streams  to  fall  upon  the  diseased  part. 
The  reservoir  is  suspended  in  the  manner  above  mentioned. 

The  limb  to  be  irrigated  is  placed  upon  a sheet  of  India-rubber 
spread  out  upon  the  bed,  and  so  arranged  that  none  of  the  water  shall 
escape  upon  the  bedclothes  or  the  person  of  the  patient,  but  may  run 
directly  from  the  limb  into  a vessel  upon  the  floor  near  the  bed. 

To  prevent  splashing  by  the  fall  of  the  fluid  upon  the  part,  it  may 
be  covered  with  a single  piece  of  linen. 

As  to  the  duration  of  the  irrigation  surgeons  have  differed  in 
opinion;  while  some  discontinue  its  use  after  five  or  six  days,  or  as 


92  WATER  IN  SURGICAL  DISEASES  AND  INJURIES. 


soon  as  suppuration  is  established,  others  advocate  its  continuance  for 
thirty  and  even  sixty  days,  or  until  cicatrization  has  begun.  Yet  it 
would  seem  to  be  the  best  rule  to  abandon  irrigation  as  soon  as  inflam- 
matory action  has  been  subdued  and  we  have  nothing  further  to  fear 
from  it,  without  regard  to  time  or  the  number  of  days  which  may 
have  elapsed. 

It  will  be  well,  also,  to  take  care  that  no  rapid  transition  of  tempera- 
ture occurs,  by  simply  using  the  cold  water-dressings  for  two  or  three 
days  after  abandoning  irrigation. 

With  a similar  view  the  temperature  of  the  water  at  the  beginning 
of  the  treatment  may  be  in  the  neighborhood  of  76°,  or  about  that  of 
the  healthy  skin,  and  then  gradually  lowered  until  the  desired  degree 
of  cold  is  obtained. 

M.  Malgaigne  gives  the  preference  to  continued  irrigation  over  every 
other  method  of  treatment  in  wounds  and  inflammations  not  very  deep- 
seated,  and  particularly  wounds  from  fire-arms,  and  those  of  the  hands 
and  feet ; while  for  other  wounds  he  prefers  intermittent  irrigations. 

Some  discrepancies  of  opinion  also  exist  as  to  the  relative  advantages 
of  cold  and  warm  irrigations.  Nelaton  would  restrict  the  former  to 
lacerated  and  contused  wounds  below  the  knee  and  elbow,  while  he 
allows  greater  latitude  to  warm  irrigation. 

Yelpeau  observes:  “I  have  remarked,  also,  that  it  (cold  irrigation) 
readily  promotes  a mortification  of  the  parts  when  the  wound  was 
accompanied  with  extensive  separations,  or  that  it  occupied  some  parts 
of  the  fingers  or  the  hand,  or  the  extremities  in  general.  I have 
observed,  in  fact,  that  while  it  prevents  or  diminishes  the  redness  of 
the  skin,  and  the  tumefaction  of  the  deeper  tissues,  it  often  masked 
inflammation,  rather  than  prevented  or  destroyed  it;  that,  therefore, 
it  does  not  prevent  the  purulent  discharges,  and  that  there  finally 
resulted  from  all  this  a thin  suppuration  of  a bad  aspect,  a general  con- 
dition of  things  of  a more  serious  nature,  and  a disposition  in  the 
wound  less  favorable  to  cicatrization  than  bv  other  kinds  of  dressing.-’ 

Sanson  states  that  tetanus  resulted  in  one  case  of  a burn  treated  by 
irrigation,  and  Legouest  adverts  to  it  as  very  often  retarding  or  mask- 
ing the  appearance  of  inflammation,  instead  of  preventing  it ; while,  on 
the  other  hand,  Josse  and  Gosselin  regard  it  of  immense  service  in 
fractures,  dislocations,  erysipelas,  phlegmon,  and  all  kinds  of  inflam- 
mations in  connection  with  wounds. 

M.  Chassaignac  has  used  irrigation  of  the  eye  for  the  treatment  of 
the  ophthalmia  of  young  infants,  and  several  inflammatory  conditions 
of  that  organ,  and  also  especially  for  the  removal  of  opacities  of  the 
cornea  which  resist  ordinary  means ; he  reports  remarkable  success 
from  the  plan  in  these  cases.  The  child  is  laid  on  a table,  and  water 
allowed  to  flow  from  a small  vessel  through  a tube  over  the  surface  of 
the  eye,  during  from  five  to  fifteen  minutes,  several  times  a day. 

Gold  Irrigation. — The  first  effects  of  cold  irrigation  are  to  diminish 
the  temperature  of  the  parts  to  which  it  is  applied,  and  to  cause  a pain- 
ful sensation  that  is  soon  followed  by  one  of  the  opposite  character. 
Yet  this  is  not  always  the  case;  for  some  patients  suffer  severe  pain 
even  during  the  whole  period  of  irrigation.  In  this  case  its  use  is 


IRRIGATIONS. 


93 


clearly  contra-indicated.  Indeed,  we  have  no  better  guide  in  applying 
cold  water  than  the  sensations  of  the  patient. 

In  gunshot  wounds  and  other  injuries  attended  with  shock  to  the 
nervous  system,  and  depression  of  the  vital  activity  of  the  injured 
parts,  reaction  should  be  first  fully  established  before  the  cold  water 
is  had  recourse  to,  as  gangreue  may  readily  be  induced  in  them.  Also 
when  from  any  cause  there  is  a tendency  to  gangrene,  its  employment 
is  contra-indicated. 

As  the  degree  of  reaction  in  a part  is  in  direct  proportion  to  the 
intensity  of  the  cold,  it  can  readily  be  imagined  that  the  intermittent 
use  of  cold  water  may  induce  a series  of  reactions  in  an  inflamed 
organ  exceedingly  prejudicial. 

The  object  of  cold  water,  as  a surgical  dressing,  is  to  obtain  its 
refrigerant  effects ; therefore,  to  avoid  the  shock  and  subsequent  reac- 
tion, its  temperature  should  be  at  first  but  a few  degrees  below  that  of 
the  healthy  skin,  and  its  volume  greater  than  will  be  necessary  at  a 
subsequent  period  when  its  temperature  is  lowered. 

Warm  Irrigations. — The  method  of  applying  warm  water  irrigation 
differs  in  no  particular  from  that  already  described  for  cold  water.  It 
may  be  employed  in  those  cases  where  the  contact  of  cold  water  with 
the  body  produces  painful  sensations,  or  where,  from  the  extent  of  the 
injury  and  the  depressed  condition  of  the  nervous  system,  cold  would 
be  likely  to  dispose  the  parts,  already  deprived  to  some  extent  of 
their  recuperative  energy,  to  mortification. 

Irrigation  of  the  Nasal  Fossse. — When  a foreign  body  gains  admis- 
sion into  the  nares,  and  cannot  be  dislodged  by  the  ordinary  means, 
a stream  of  water  thrown  from  the  direction  of  the  pharynx  will  often 
effect  it. 

The  sedative  effects  of  cold  water,  or  the  emollient  ones  of  warm 
water  can  be  obtained  in  the  same  manner  in  inflammatory  affections, 
ulcerations,  or  other  morbid  changes  of  the  mucous  membrane  lining 
that  cavity. 

The  advantage  of  the  plan  is  that  any  liquid  can  be  brought, 
continuously,  in  contact  with  the  entire  extent  of  surface  of  the  nasal 
fossae  and  pharynx ; while  by  inclining  the  patient’s  head  forward,  no 
part  of  it  flows  into  the  gullet  or  trachea. 

Solutions  of  the  nitrate  of  silver,  the  bichloride  of  mercury,  the  sul- 
phates of  zinc  and  copper,  or  anjr  other  metallic  salt,  or  astringent  sub- 
stances may,  likewise,  be  successfully  used  in  the  treatment  of  chronic 
coryza  and  ozaena.  I have  lately  cured  a case  of  the  latter  disease  of 
long  standing,  in  a young  man,  by  the  injection  of  a strong  solution  of 
nitrate  of  silver. 

The  apparatus  which  I have  constructed  for  this  purpose  consists 
of  a long  slender  tube  of  vulcanized  rubber,  bent  at  its  distal  extre- 
mity into  a hook,  the  point  of  which  is  perforated  with  four  holes, 
while  the  proximal  end  is  furnished  with  a male  screw. to  fasten  to  a 
syringe,  or  to  the  India-rubber  ball  pump,  according  as  an  intermit- 
tent or  continuous  action  of  the  fluid  is  required.  I always  employ 
the  syringe  when  using  strong  solutions  of  the  metallic  salts. 

The  best  manner  of  making  the  injection  or  irrigation  is  to  place 


94  WATER  IN  SURGICAL  DISEASES  AND  INJURIES. 


the  patient  in  a chair  facing  the  window,  with  his  head  thrown  back 
and  his  mouth  widely  open.  The  operator  then  passes  the  long  tube 
held  in  his  right  hand  through  the  fauces,  and  hooks  its  point  behind 
the  soft  palate,  and  after  flexing  the  patient’s  head,  he  forces  the  fluid 
into  the  nares,  the  former  running  from  the  nose  freely. 

Irrigation  of  the  Bladder. — Diseases  of  the  bladder,  such  as  inflam- 
mation, hemorrhage,  and  stone,  are  sometimes  very  much  benefited 
by  warm  or  cold  irrigations.  It  can  be  accomplished  by  the  double- 
tubed  catheter  seen  in  the  figure.  (Fig.  61.)  The  dotted  line  indicates 


Fig.  61. 


Double-tubed  catheter. 


the  septum  of  division,  and  the  arrows  the  course  of  the  fluid,  as  it  passes 
along  the  upper  compartment  to  issue  from  the  hole  upon  the  con- 
cavity of  the  curve  into  the  bladder,  when  it  again  enters  the  cathe- 
ter by  the  hole  upon  the  convexity  to  emerge  through  the  lower  divi- 
sion, externally.  The  wire  stylet  (c)  is  used  to  keep  the  catheter 
clear  of  clots  of  blood,  sabulous  matters,  or  other  obstructions.  The 
water  injected  may  be  simple,  or  variously  medicated  to  answer  spe- 
cial indications.  It  is  forced  through  the  instrument  by  a syringe,  or, 
what  is  better,  the  India-rubber  ball  pump. 

Irrigation  of  the  Uterus  and  Vagina. — For  the  purpose  of  irrigating 
the  vagina  and  uterus  various  contrivances  have  been  invented,  but 
none  of  them  are  so  elegant  and  useful  as  that  of  Maisonneuve.  It  is 
extremely  ingenious,  and  deserves  a particular  notice  in  this  place. 

As  seen  in  Fig.  62,  the  vaginal  portion  of  the  apparatus  consists  of  a 
hollow  frustum  of  a cone  of  ebony  or  vulcanized  rubber  with  vertical 
slits,  and  sufficiently  large  to  distend  the  vagina  moderately.  Through 
this  cone  runs  a metallic  tube  terminating  at  its  apex  in  a perforated 
disk  like  the  rose  of  a common  watering  pot;  the  proximal  end  of  the 
tube  projects  from  the  base  of  the  cone,  and  has  attached  to  it  a long 
flexible  India-rubber  tube  with  a rubber  ball  pump  upon  its  middle. 


WATER  BY  MEANS  OF  INDIA-RUBBER  SACKS. 


95 


Another  tube  of  the  same 
material  is  attached  to  the 
base  of  the  cone,  near  the 
former,  to  carry  off  the  waste 
■water  entering  it  through 
the  slits. 

The  patient  can  use  the 
instrument  herself  without 
wetting  her  person  or  the 
bedclothes,  by  simply  re- 
clining upon  her  back  with 
the  cone  introduced  into  the 
vagina,  then  by  pressing 
upon  the  ball  grasped  in 
the  hand  the  water  will  be 
forced  from  the  basin,  in 
which  the  bell-shaped  ex- 
tremity of  the  tube  is  im- 
mersed, into  the  vagina. 
Another  vessel  should  be 
placed  near  the  bed  to  col- 
lect the  waste  water  from 
the  discharging  tube. 

A number  of  uterine  and 
vaginal  diseases  may  be 
advantageously  treated  in 
this  manner,  such  as  obsti- 
nate cases  of  leucorrhoea, 
which  will  often  yield  to 
the  continued  use  of  cold 
water.  It  is  a good  way  of 
applying  cold  in  uterine 
hemorrhage,  and  astrin- 
gent solutions  in  inflamma- 


Fig.  62. 


tory  affections  of  the  vagi-  Maisonneuve’s  irrigator, 

nal  mucous  membrane. 

The  Application  of  W ater  by  Means  of  India-rubber  Sacks.— 
There  are  some  disadvantages  attending  irrigation,  such  as  the  difficulty 
of  keeping  up  a uniform  temperature,  the  wetting  of  the  patient  or  the 
bedclothes,  the  disposition  of  the  cold  water  to  cause  inflammatory 
affections  of  the  chest,  and  lastly,  in  some  instances,  the  inability  of 
confining  the  water  with  precision  to  any  given  part  by  the  restless- 
ness of  the  patient,  or  from  his  tender  age  precluding  the  exercise  of 
proper  judgment. 

Although  the  present  method,  in  a measure,  does  away  with  these 
disadvantages,  yet  it  is  not  itself  free  from  all  objections  and  incon- 
venience : of  which  we  may  instance  as  the  principal  the  weight  of  the 
sacks,  and  the  expense  attending  their  manufacture. 

I am  convinced  by  numerous  trials  that  there  are  cases  in  which 
their  utility  is  incontestable.  Two  cases  of  perforating  fracture  of  the 
skull  with  cerebral  inflammation  came  under  my  care  in  which  the 


96  WATER  IN  SURGICAL  DISEASES  AND  INJURIES. 

delirium  was  such,  that  it  was  impossible  to  keep  any  kind  of  dress- 
ings upon  the  head  without  having  present  two  or  three  persons  to 
restrain  the  violence  of  the  patients.  Here  the  ice  cap  answered  an 
admirable  purpose,  as  it  could  be  securely  fastened  to  the  head  by 
means  of  the  chin  straps  attached  to  it.  In  such  cases  the  ice  blad- 
ders will  not  answer  any  better  than  cold  water-dressings,  for  their 
very  shape,  when  filled  with  ice  or  cold  water,  will  cause  the  edges 
to  bulge  to  such  an  extent  that  it  would  be  impossible  either  to 
cover  the  head  entirely  by  them,  or  to  retain  them  in  place  unless  by 
the  assistance  of  attendants.  Besides,  in  my  experience  in  the  hos- 
pitals during  the  late  war,  bladders  were  not  attainable  while  there 
was  an  abundance  of  oiled  silk  to  be  found,  of  which  a very  good 
substitute  for  the  India-rubber  cap  can  be  made. 

The  heat  of  the  scalp  is  such,  at  times,  that  the  water  in  the  bladders 
is  soon  rendered  warm,  and  needs  frequent  renewal,  in  the  same  man- 
ner as  the  cold  water-dressings.  These  disadvantages  are  perfectly 
overcome  with  the  India-rubber  cap,  which  covers  the  whole  head 
above  the  face  and  ears,  and  can  be  so  secured  by.  the  ribbons  tied 
beneath  the  chin  that  the  patient  cannot  displace  the  cap  by  his  rest- 
lessness ; it  does  not  permit  the  water  to  run  over  his  neck  and  chest, 
and  thus  produce  chills,  colds,  and  even  inflammatory  affections  of  the 
thorax.  With  a supply  tube  of  India-rubber,  and  another  of  discharge, 
water  of  any  temperature  can  be  kept  constantly  passing  through  the 
cap,  thus  securing  a never-varying  temperature,  a condition  essential 
in  the  correct  treatment  of  inflammation  by  cold. 

The  Cap  (Fig.  63)  is  composed  of  double  layers  of  India-rubber  cloth 
formed  somewhat  in  the  shape  of  a helmet.  With  the  interior  of  this 
two  India-rubber  tubes  communicate,  one  for  sup- 
plying the  water  from  a vessel  while  the  other  (c) 
conveys  it  away  from  the  cap  to  a basin.  By 
means  of  the  stopcock  of  the  reservoir,  the  flow 
of  the  fluid  is  regulated,  so  that  a constant  supply 
of  uniform  temperature  reaches  the  head.  At  the 
apex  of  the  cap  is  seen  an  orifice  ( b ) communicating 
with  the  scalp  and  furnishing  a ready  outlet  for 
the  perspiration. 

Besides  the  cases  I have  already  mentioned, 
in  which  the  cap  has  been  used  advantageously, 
I may  also  mention  all  those  diseases  attended 
with  vascular  or  cerebral  excitement,  obstinate 
cephalalgia,  and  especially  that  resulting  from 
the  effects  of  an  inordinate  indulgence  in  alco- 
holic stimulants.  In  a very  few  moments  the 
sedative  action  of  the  cold  water  is  marked,  the 
pain  disappears,  and  the  patient,  before  tossing 
about  insomnious,  becomes  quiet  and  finally  falls  into  a gentle  sleep. 

The  Cervical  Sack. — In  affections  of  the  neck  and  throat  we  can  also 
avail  ourselves  of  the  advantages  of  hot  and  cold  water  by  means  of 
the  cervical  sack  which  fits  those  parts  and  rests  upon  the  shoulders 
and  the  upper  part  of  the  sternum. 


Fig.  63. 


India-rubber  cap  for  apply- 
ing cold  water  to  the  head. 


WATER  BY  MEANS  OF  INDIA -RUBBER  SACS. 


97 


The  Spinal  Sack. — This  has  recently  been  much  used  in  obstinate 
cases  of  spinal  tenderness  or  pain,  and  in  diseases  depending  upon  vas- 
cular congestion  of  the  cord.  Mr.  Chapman,  of  London,  recommends  it 
highly  in  cholera.  This  gentleman  remarks : “ The  bags  I use  are  of 
different  lengths;  of  the  width  already  named”  (four  to  four  and  a 
half  inches)  “for  adults,  and  of  lesser  widths,  of  course,  for  children. 
I have  had  them  made  both  of  India-rubber  and  of  linen  with  a sur- 
face of  India-rubber  upon  it ; the  former  are  the  best.  The  width  of 
the  bags  is  equal  throughout,  except  at  the  opening,  which  is  narrowed 
to  facilitate  tying,  and  elastic  to  admit  easily  the  lumps  of  ice.  When 
the  bag  is  full,  I divide  it,  if  a large  one,  into  three  segments ; this  can 
be  done  by  constricting  it  forcibly  with  a string  ; the  ice  of  the  upper 
part  is  thus  prevented  from  descending,  as  the  melting  goes  on,  into 
the  lower  part  of  the  bag.”  He  bases  the  employment  of  the  spinal  sack 
upon  the  belief  that  a “ controlling  power  over  the  circulation  of  the 
blood  in  the  brain,  in  the  spinal  cord,  in  the  ganglia  of  the  sympathetic 
nervous  system,  and  through  the  agency  of  these  nervous  centres, 
also  in  every  other  organ  of  the  body,  can  be  exercised  by  means  of 
cold  and  heat  applied  to  different  parts  of  the  back.  In  this  manner 
the  reflex  excitability,  or  excito-motor  power  of  the  spinal  cord,  and 
the  contractile  force  of  the  arteries  in  all  parts  of  the  body,  can  be 
immediately  modified.” 

The  facility  of  passing  alternately  hot  and  ice-cold  water  through 
these  sacks  will  recommend  them  in  the  treatment  of  bed-sores  after 
the  plan  of  Brown-Sdquard,  which  consists  in  the  alternate  application 
for  ten  minutes  or  more  at  a time,  of  iced  water  and  hot  poultices. 

The  Thoracic  Sack  will  enable  the  physician  to  surround  the  chest 
with  water  of  any  temperature,  the  utility  of  which  in  inflammatory 
disease  of  the  thorax,  as  pneumonia  and  bronchitis,  is  undoubted.  W e 
have  already  spoken  of  the  advantages  of  the  oil-silk  or  India-rubber 
jacket  in  this  class  of  cases,  and  we  have  only  to  remark  that  its 
action  is  somewhat  similar  to  that  of  the  thoracic  sack  supplied  with 
warm  water,  differing  only  in  degree. 

The  Abdominal  Sack  is  constructed  upon  exactly  the  same  principles 
as  the  cap,  and  will  be  found  useful  in  the  treatment  of  colic,  spasms 
of  the  intestines,  in  the  passage  of  a gall-stone,  strangury,  and  inflam- 
matory affections  of  the  abdominal  organs,  particularly  peritonitis. 
M.  Behier,  at  the  Session  of  the  French  Academy  of  Medicine,  April 
1,  1862,  stated  that,  “ since  October,  1858,  801  females  were  confined 
at  the  Hopital  Beaujon ; to  355  of  these  females  ice  was  applied;  241 
of  the  patients  presented  merety  swelling  of  the  annexes  of  the  uterus, 
accompanied  with  slight  pain,  which  soon  disappeared.  In  68  the 
symptoms  were  of  a more  menacing  character,  with  a decided  febrile 
reaction  and  a commencing  alteration  of  the  patient’s  features.  39  of 
the  801  parturients  died.  But  even  in  these  cases  the  application  of 
the  ice  postponed  the  fatal  result  beyond  the  customary  period  at 
which  it  happens  in  cases  where  ice  had  not  been  applied.”  The  ice 
was  retained  in  contact  with  the  abdomen  by  means  of  caoutchouc  bags. 

The  thoracic  and  abdominal  sacks  may  be  joined,  when  the  object  is 
to  stimulate  the  system  powerfully,  by  hot  water  applied  to  a large 
7 


98  WATER  IN  SURGICAL  DISEASES  AND  INJURIES. 

extent  of  the  surface,  as  in  the  collapse  from  cholera,  severe  injury, 
etc.  This  plan  is  superior  to  that  of  applying  hot  bricks,  bottles  of 
water,  etc.,  which,  besides  being  troublesome,  are  continually  under- 
going variations  in  temperature,  and  come  in  contact  with  only  a very 
limited  extent  of  the  skin. 

The  Scrotal  Sack  may  be  used  in  orchitis,  spasmodic  stricture,  and 
retention  of  urine,  etc. 

Water  Cushions,  of  any  desired  shape  or  size,  may  be  constructed 
in  the  same  manner,  and  used  in  the  treatment  of  fractures  of  the 
extremities  and  the  spine. 

Sacks  for  the  Upper  and  Lower  Extremities. — In  the  few  cases  of 
chronic  rheumatism  in  which  I have  tried  warm  water,  by  means  of 
these  sacks,  advantage  was  obtained  in  the  mitigation  of  the  pain,  and 
thus  the  patient’s  condition  rendered  more  comfortable. 

SECTION  II. 

THE  USE  OF  WATER  GENERALLY— BATHING. 

We  have  already  alluded  to  the  antiquity  of  bathing,  both  as  a 
sanative  measure  and  as  a luxury,  and  also  of  its  universal  employ- 
ment at  the  present  time  for  this  twofold  object.  We  propose  here 
to  consider  it  only  in  its  surgical  relations  and  uses. 

Baths  may  be  classed  either  according  to  the  nature  of  the  medium 
into  which  the  body  is  immersed,  or  according  to  the  extent  to  which 
the  body  is  immersed  into  that  medium.  By  the  first  method  baths 
are  arranged  into  the  simple  water,  the  vapor,  and  the  dry  baths. 

But  the  second  plan,  which  divides  baths  into  general  and  local, 
will  answer  our  purpose  better,  and  we  shall  therefore  adopt  it. 

General  Baths. — General  baths  are  either  simple  or  medicated ; 
and  they  vary  in  their  therapeutical  effects  according  to  the  tempera- 
ture of  the  water  employed,  the  manner  of  its  application,  and  the 
nature  of  the  medicinal  impregnation. 

The  thermometer  may  be  relied  upon  as  a general  guide  in  using 
baths,  but  the  sensations  of  the  patient  will  alone  indicate  the  precise 
effects  of  bathing ; for  the  reason  that  a temperature  which  for  one 
person  might  give  the  sensation  of  cold,  will  in  another  produce  one 
of  an  opposite  character.  Though  Dr.  Forbes  has  thought  that  it 
would  be  convenient  to  decide  upon  some  particular  temperature  as 
the  dividing  line  between  these  two  classes  of  sensations,  and  he  has 
selected  that  of  85°  Fahr.;  denominating  all  baths  of  a temperature 
above  this  warm,  and  all  those  below  it  cold. 

Influenced  also  by  motives  of  practical  utility  in  their  employment, 
he  advises  a further  classification:  A.  Cold  Baths. — 1.  The  Cold 
Bath,  from  83°  to  60°;  2.  The  Cool  Bath,  60°  to  75°;  3.  The  Tem- 
perate Bath,  75°  to  85°.  B.  Warm  Baths. — 1.  The  Tepid  Bath, 
85°  to  92°;  2.  The  Warm  Bath,  92°  to  98°;  3.  The  Hot  Bath.  98° 
to  112°. 

It  will  be  seen  that  in  these  baths  we  obtain  a range  of  79°  of  tem- 
perature, from  83°  to  112°,  which  will  be  found  amply  sufficient  for 


BATHING. 


99 


all  practical  purposes,  though  occasionally  a higher  degree  than  112° 
has  been  resorted  to. 

The  immediate  effects  of  an  immersion  in  water  between  32°  and 
35°  of  temperature  are  horripilation  and  numbness  of  the  surface,  con- 
vulsive anhelation,  tremblings  of  the  limbs,  chattering  of  the  teeth, 
and  pain  in  the  head ; these  effects  will  be  more  marked  if  the  body 
changes  its  position  so  as  to  bring  fresh  quantities  of  cold  water  in 
contact  with  the  skin.  If  the  immersion  is  continued  five  or  sis 
minutes  longer,  violent  pains  in  the  stomach  and  acute  pains  along 
the  course  of  the  muscles  will  ensue ; the  pulse  becomes  quick  and 
small,  the  respiration  accelerated  and  oppressed,  and  the  general 
sensibility  much  blunted.  A longer  stay  yet  in  the  water,  and  these 
symptoms  will  be  followed  by  stupor  and  death. 

If  the  temperature  is  more  elevated,  and  the  patient  in  vigorous 
health,  other  phenomena  show  themselves ; the  vital  powers  are  roused 
into  an  increased  activity,  so  that  the  shock  is  soon  followed  by  reac- 
tion, the  pulse  expands,  the  respiration  becomes  freer,  and  the  unplea- 
sant sensations  give  way  to  others  of  an  agreeable  kind,  a glow  dif- 
fuses itself  over  the  surface,  and  the  patient  feels  as  if  possessed  of 
renewed  strength. 

After  a longer'  or  shorter  period,  according  to  the  degree  of  cold 
and  the  activity  of  the  constitutional  powers,  if  the  bath  is  continued, 
the  vital  activities  within  cease  to  struggle  so  energetically  with  the 
physical  forces,  and  in  consequence,  reaction  will  be  succeeded  by  a 
sensation  of  cold,  the  phenomena  at  first  described  will  reappear,  and 
the  system  will  become  powerless  and  exhausted. 

We  observe  clearly  in  all  these  -phenomena  three  elements,  viz., 
shock,  refrigeration,  and  reaction,  which  it  is  important  to  separate, 
as  each  has  its  own  individual  action  and  influence  upon  disease.  For 
instance : in  torpor  of  the  nervous  system,  as  in  syncope,  we  dash  cold 
water  in  the  face  to  rouse  it  into  action  by  the  shock  impressed ; here 
any  degree  of  refrigeration  would  be  pernicious,  while,  on  the  other 
hand,  in  febrile  disturbance  and  acute  inflammations  we  endeavor  to 
obtain  the  refrigeration  without  the  first  and  third  elements. 

We  have  already  spoken,  elsewhere,  of  the  injurious  effects  result- 
ing from  the  intermittent  application  of  cold  water  in  local  inflamma- 
tion, and  feel  convinced  that  often  more  injury  than  good  results  from 
its  use  in  many  cases  from  want  of  due  consideration  of  its  physiologi- 
cal effects. 

As  a therapeutical  agent,  cold  bathing  is  one  of  the  most  powerful 
tonics  in  the  whole  range  of  the  Materia  Medica,  and  hence  its  great 
use  in  debilitated  conditions  of  the  system.  In  these  cases,  however, 
care  should  be  taken  that  the  temperature  be  not  too  low,  for  desirable 
as  such  a temperature  may  be  as  a corroborant,  we  should  not,  on  the 
other  hand,  forget  that  a fatal  languor  may  be  induced. 

The  cool  bath  from  60°  to  76°  will  answer  very  well  as  a tonic  in 
debility  as  well  as  for  persons  advanced  in  years,  and  for  the  young 
who  do  not  bear  cold  as  well  as  the  middle  aged  and  vigorous.  The 
shock  is  slight,  and  in  a little  while  the  skin  glows  with  a delightful 
freshness. 


100  WATER  IN  SURGICAL  DISEASES  AND  INJURIES. 


Water  near  the  temperature  of  the  skin  produces  little  other  effect 
beyond  the  mechanical  action  of  its  weight,  and  may  be  employed 
for  the  purposes  of  cleanliness,  and  where  the  object  is  to  remove 
adhering  dust  or  crusts  which  plug  up  the  exhalant  orifices  and  de- 
range the  perspiratory  function,  and  thereby  cause  sensations  of  itching, 
and  a pimply  skin. 

The  warm  bath,  92°  to  98°,  produces  results  opposite  to  those  of 
the  cold  bath,  giving  rise  to  pleasant  sensations  when  the  body  is 
immersed  in  it,  gently  exciting  the  skin,  and  favoring  transpiration. 
It  soothes  the  nervous  system,  relieves  pain,  and  at  the  same  time 
excites  it  to  healthy  action ; it  promotes  the  circulation,  and  thereby 
favors  an  equable  distribution  of  the  blood  through  the  whole  system. 

The  hot  bath  of  100°  and  upwards  is  still  more  stimulating,  pro- 
ducing increased  action  of  the  vascular  system ; the  heart  beats  more 
rapidly,  and  the  vessels  of  the  head  sometimes  throb  painfully,  while 
the  superficial  vessels  are  gorged  with  blood. 

Soon,  however,  this  increased  action  gives  way  to  a corresponding 
degree  of  relaxation,  a profuse  perspiration  breaks  out  upon  the  sur- 
face which  relieves  the  general  tension  of  the  vessels.  The  patient 
will  then  labor  under  a lassitude  for  some  time  after  coming  out  of  the 
bath. 

When  the  body  is  sponged  with  water  from  120°  to  130°  tempera- 
ture, or  immersed  in  a bath  of  a temperature  that  the  patient  can  bear 
without  pain,  the  skin  becomes  hot,  red,  and  dry,  and  remains  so  for 
some  time,  little  or  no  sedation  being  observed  to  follow.  My  atten- 
tion was  first  called  to  this  e fleet  of  hot  water  some  years  ago  by  a 
French  gentleman,  a traveller  in  India,  who  was  in  the  habit  of  having 
constant  recourse  to  it  when  about  to  begin  a long  and  fatiguing  jour- 
ney under  a torrid  sun,  and  also  after  completing  it.  He  assured  me 
it  gave  him  greater  endurance  and  checked  profuse  perspiration.  The 
remedy  will  be  of  service  in  those  diseases  attended  with  undue  per- 
spiratory activity,  as  in  phthisis. 

When  removed  from  the  warm  bath,  the  patient  should  be  carefully 
dried  with  a coarse  towel,  and  sheltered  from  drafts  of  air  and  the 
inequalities  of  temperature  of  his  chamber. 

As  a sedative  the  warm  bath  is  used  to  assuage  the  pain  from  vio- 
lent muscular  contractions,  as  in  colic  and  cramps,  and  to  relax  the 
muscles  during  the  operation  of  the  taxis,  and  spasmodic  contraction 
of  the  neck  of  the  bladder. 

As  an  indirect  tonic  it  may  be  employed  in  debility,  and  as  a stimu- 
lant in  extreme  exhaustion  with  a concentration  of  the  nervous  ener- 
gies and  circulating  fluids  upon  the  interior  organs.  In  chronic  skin 
diseases,  also,  the  warm  bath  is  advantageous  as  a stimulant  to  alter  its 
physical  and  vital  states. 

Here  we  can  see  that  the  stimulant  effects  of  a warm  bath  may  be 
separated,  to  some  extent,  from  the  sedative  effects,  simply  by  the 
method  of  its  application : an  important  object  in  cases  of  debility  in 
which  any  amount  of  sedation  would  be  pernicious.  To  accomplish 
the  object  the  bath  should  be  of  a temperature  from  9S°  to  112°,  and 
continued  for  a few  moments  only. 


BATHING. 


101 


In  large  cities  baths  may  be  obtained  at  any  time,  and  even  in 
private  dwellings  the  most  elaborate  arrangements  may  be  found  for 
this  purpose.  Where  these  conveniences  are  not  attainable,  the  simple 
contrivance  (Fig.  64)  recommended  by  Dr.  Thomson  will  answer  the 
purpose. 

He  describes  it  as  “consisting  of  a hammock  (a)  of  Macintosh’s 
cloth,  which  is  extended  upon  two  long  poles  ( bb ),  passed  through  a 


Fig.  64. 


Thomson’s  bathing  apparatus 


broad  seam  on  each  side  of  the  hammock,  and  kept  asunder  by  the  cross 
pieces  (cc)  which  are  attached  to  the  pole  by  the  thumb-screws  (ddd). 
At  one  end  of  the  hammock  is  an  air  pillow,  which  can  be  readily 
blown  up,  and  below  it  is  a flexible  tube  (/)  made  of  the  same  mate- 
rial as  the  hammock,  by  which  any  water  it  may  contain  can  be 
readily  drawn  off.  When  the  poles  are  fixed,  as  in  the  above  figure, 
and  the  open  end  of  the  flexible  tube  is  twisted  around  one  of  the 
thumb-screws,  the  bath  is  ready  to  receive  the  water.  It  may  be  sup- 
ported upon  two  chairs,  or  upon  folding  tressels  (ee).  The  advantage 
of  this  bath  is,  that  it  requires  a very  small  quantity  of  water  com- 
pared to  that  demanded  for  other  baths ; that  it  requires  no  sheet  for 
the  bather  to  rest  upon;  and  when  the  bathing  is  completed,  the 
poles  and  the  folding  tressels  can  be  placed  aside  in  a small  closet 
or  in  the  corner  of  a dressing-room,  and  the  hammock,  when  dried,  put 
into  a drawer.” 

For  portability  I have  adopted  a bathing-tub  made  of  India-rubber, 
and  having  hollow  walls,  between  which  air  is  forced  by  means  of  a 
pair  of  bellows.  After  the  tub  has  been  used  it  should  be  wiped  dry 
and  the  air  squeezed  out  of  its  walls,  when  it  may  be  folded  up  in  a 
small  package  and  kept  in  a drawer. 

In  the  absence  of  either  of  these  contrivances,  a common  washing 
tub  or  large  barrel  may  be  used  instead. 

The  Shower  Bath  may  be  either  general  or  local,  and  its  effect  will 
vary  with  the  temperature,  volume,  and  the  height  from  which  the 
water  falls  upon  the  patient,  but  their  general  character  will  be  pretty 
much  the  same  as  those  of  the  plunge  bath  of  the  same  temperature. 
It  possesses  the  advantage,  however,  of  enabling  the  practitioner  to 
localize  the  action  of  the  water  in  such  a manner  that  the  shock  and 
diminished  temperature  may  be  brought  to  bear  directly  upon  any 
given  part,  and  thus  any  general  perturbation  of  the  system  will  be 
avoided,  if  it  is  so  desired. 


102  WATEE  IN  SUEGICAL  DISEASES  AND  INJUEIES. 


Again,  some  patients  cannot  bear  the  mechanical  effects  of  the  water 
of  a plunge  bath  upon  their  bodies,  as  it  produces  a feeling  of  suffoca- 
tion and  an  indescribable  sense  of  uneasiness  : here  the  shower  bath 
will  be  found  an  efficient  substitute. 

In  many  dwellings  shower  baths  are  arranged  in  such  a manner 
that,  by  means  of  a stopcock  furnished  for  the  purpose,  the  force  and 
quantity  of  the  falling  water  may  be  increased  or  diminished  accord- 
ing to  the  tolerance  of  the  patient. 

A portable  shower  bath  (Fig.  65)  is  now  manufactured,  consisting  of 
a tin  vessel  of  half  a gallon,  or  a gallon  capacity,  with  its  bottom  per- 
forated with  numerous  holes.  Its  inte- 
rs- rior  communicates  with  the  air  through 


a small  tube  running  in  the  handle  of 
the  vessel,  and  terminates  at  its  top  by 
a small  hole  which  can  easily  be  covered 
with  the  pulp  of  the  index  finger. 

When  we  desire  to  use  the  vessel  it 
should  be  immersed  in  a pail  of  water, 
and  the  orifice  above  spoken  of  closed 
with  the  point  of  the  finger,  which  will 
cause  the  water  to  be  retained  in  the 
vessel,  after  it  is  lifted  from  the  pail, 
by  atmospheric  pressure. 

The  patient  may  now  hold  the  tin 
over  his  head,  and  by  raising  the  finger 
from  the  hole  the  water  will  shower 
upon  his  person. 

Portable  shower  bath.  Affusion  is  a rude  sort  of  shower  bath, 

and  consists  in  simply  dashing  water 
from  a bucket  over  a person,  yet  it  produces  much  less  shock  than  the 
former. 

The  vapor  bath  resembles,  in  its  general  effects,  those  of  the  warm 
bath  already  described,  the  chief  points  of  difference  being  that,  at 
corresponding  degrees  of  temperature,  the  vapor  bath  is  more  sudo- 
rific and  derivative,  while  at  the  same  time  it  is  much  less  stimulant 
and  soothing  to  the  nervous  system,  cseteris  paribus,  than  the  warm 
bath. 

If  the  whole  body  is  immersed  in  the  vapor,  which  is  breathed  at 
the  same  time,  its  heating  effects  will  be  much  increased,  because  the 
inhalation  stops  the  cooling  process  taking  place  by  evaporation  from 
the  lungs,  and  also  furnishes  just  so  much  more  space  for  the  heating 
medium  to  act  upon,  as  there  are  square  inches  of  bronchial  surface. 
Hence,  it  will  be  necessary,  under  these  circumstances,  to  employ  vapor 
of  a lower  temperature  than  where  the  exterior  of  the  body  alone  is 
exposed. 

The  physical  law  is,  that  the  heating  power  of  a medium  depends 
upon  its  density,  conductivity,  and  capacity  for  caloric,  being  greater 
where  these  properties  are  possessed  in  greater  degree : it  follows 
then  that  the  relative  heating  power  of  water  and  vapor  will  differ 
considerably. 


BATHING. 


108 


The  ratio  of  difference  is  expressed  in  the  following  comparative 
view  drawn  up  by  Dr.  Forbes: — 


Water. 

Vapor. 

Not  breathed.  Breathed. 

Tepid,  bath  .... 

Warm  bath  .... 

Hot  bath  .... 

85° — 92° 
92° — 98° 
98°— 106° 

96° — 106° 
106°— 120° 
120°— 160° 

90°— 100° 
100°— 110° 
110°— 130° 

The  cases  in  which  the  vapor  bath  is  employed  are  marked  by  the 
retrocession  of  the  fluids  upon  the  central  organs,  as  in  the  cold  stage 
of  fever  and  the  collapse  of  cholera.  It  is  also  used  to  alter  the  action 
of  the  skin  in  cutaneous  diseases,  and  to  remove  the  stiffness  and 
rigidity  of  the  muscles  and  joints. 

Local  vapor  baths  have  also  been  recommended  and  employed  by 
Dr.  Macartney  in  painful  wounds,  contusions,  and  fractures.  In  otitis 
and  otalgia  a stream  of  warm  vapor  may  be  introduced  into  the  ex- 
ternal meatus  by  means  of  a funnel  inverted  over  a vessel  of  hot 
water,  the  small  end  being  placed  in  the  meatus.  The  vapor  bath  is 
also  occasionally  medicated  with  the  volatile  and  odoriferous  constitu- 
ents of  certain  plants  and  balsams. 

Blegborough  recommended  an  air-pump  vapor  bath  in  gout,  rheu- 
matism, and  paralysis. 

There  are  elaborate  apparatus  sometimes  prepared  for  the  adminis- 
tration of  the  vapor  bath,  but  generally  an  extemporized  apparatus 
that  can  be  gotten  up  in  any  household  will  serve  pretty  nearly  as 
well. 

If  the  patient  can  sit  up,  place  him  upon  a stool  under  which  a 
basin  of  hot  water  is  introduced,  and  surround  him  with  a thick 
blanket,  or  a sheet  of  India-rubber  cloth,  in  such  a manner  that  it  may 
hang  down,  all  around,  upon  the  floor : if  he  is  not  to  breathe  the 
vapor,  it  should  be  fastened  above,  around  his  neck.  In  the  contrary 
case,  the  head  may  be  inclosed  and  the  blanket  supported  above  it  by 
a common  keg-hoop  firmly  tied  to  the  top  of  a stick,  bound  below  to 
one  of  the  legs  of  the  stool. 

Everything  being  now  ready,  a hot  brick  is  placed  in  the  basin, 
from  the  water  contained  in  which  steam  will  rise  in  abundance  and 
fill  the  space  between  the  patient’s  body  and  the  blanket. 

Another  plan  quite  as  simple  is  to  reverse  over  a patient,  seated 
upon  a stool,  a common  wicker  basket  with  a hole  in  the  side  for  the 
patient  to  protrude  his  head  at  pleasure.  The  basket  is  covered  with 
a blanket  likewise  perforated,  and  the  steam  is  admitted  from  below 
by  means  of  a tube  coming  from  the  spout  of  a teakettle  filled  with 
water  and  kept  boiling  upon  a fire  near  at  hand. 

If  the  patient  is  confined  to  his  bed,  the  blanket  may  be  supported 
over  his  person  by  two  or  three  hoops  nailed  to  a piece  of  stiff  wood 
five  or  six  feet  long.  The  steam  is  obtained  from  a boiling  kettle,  as 
in  the  former  case. 

Dr.  J.  B.  Nevins,  of  Liverpool,  has  suggested  a very  simple  method 


104  WATER  IN  SURGICAL  DISEASES  AND  INJURIES. 

of  employing  a vapor  bath  while  the  patient  rests  in  his  bed : he 
directs  that  “ two  pieces  of  coarse  flannel  (common  scouring  cloths 
answer  the  purpose  admirably)  are  to  be  soaked  in  common  vinegar, 
about  a pint  being  necessary  for  each  cloth.  Two  common  bricks 
are  then  to  be  heated  nearly  red-hot  in  the  fire,  folded  up  in  these 
flannels,  and  placed  on  two  plates.  The  patient  being  stripped,  one 
plate  is  to  be  put  a little  distance  from  one  knee,  and  the  other  a little 
distance  from  the  opposite  shoulder,  and  the  patient  is  to  be  covered 
over  with  the  bedclothes.  In  a few  minutes  he  is  surrounded  by  a 
most  refreshing  steam  bath,  which  produces  a warm,  agreeable  per- 
spiration, that  may  be  kept  up  for  twenty  minutes  or  longer,  if  the 
bricks  retain  their  heat  sufficiently.”  In  this  manner,  he  says,  he  has 
treated  acute  rheumatism  for  a number  of  years,  with  great  success, 
always  following  the  vapor  bath  with  the  cold  douche,  Avhich  is  accom- 
plished in  this  way  : “As  soon  as  it  is  decided  to  remove  the  bricks, 
the  patient,  still  in  bed,  is  to  be  very  rapidly  mopped  all  over  with 
towels  wrung  out  of  cold  water,  then  immediately  wiped  dry  with  dry 
towels,  supplied  with  a warm  shirt  or  flannel  garment,  and  covered 
with  a fresh,  dry  sheet,  etc.,  or  with  blankets  alone,  as  may  be  most 
agreeable  to  him.” 

“ The  cold  water  application  immediately  on  the  removal  of  the 
hot  vapor  is  very  important,  as  it  prevents  the  continuance  of  an 
enfeebling  perspiration  after  the  hot  bath.” 

The  Warm  Air  Bath  possesses  some  of  the  qualities  of  the  vapor 
bath.  It  is  more  stimulating  and  sudorific  than  the  latter,  but  much 
less  soothing  and  relaxing.  It  may  be  employed  in  the  same  class  of 
cases,  and  more  especially  in  the  dry  scaly  eruptions  of  the  skin.  The 
sudatorum  of  Dr.  Gower  is  made  with  hoops,  in  the  same  manner  as 
the  apparatus  for  the  vapor  bath  already  described ; the  tube  commu- 
nicating with  its  interior  has  a bell-shaped  opening  externally,  under 
which  a spirit  lamp  is  to  be  placed.  He  states  that  a temperature  of 
85°  produces  a profuse  perspiration,  and  that  above  this  “the  effect 
would  be  rather  frustrated,  owing  to  the  ardent  heat  which  the  patient 
feels  and  complains  of,  without  obtaining  the  relief  which  sweating 
invariably  produces.” 

Dry  Baths  consist  of  some  solid  matters  into  which  the  body  is 
immersed.  Formerly  the  buccaneers  of  the  West  Indies  were  in  the 
habit  of  burying  those  of  their  comrades  affected  with  scurvy  up  to 
their  necks  in  the  sand,  the  warmth  of  which  produced  copious  per- 
spiration. 

A disgusting  practice,  still  pursued  by  the  common  people  in  some 
parts  of  the  world,  is  to  immerse  patients  in  the  blood  of  recently 
killed  animals,  mud,  masses  of  the  husks  of  grapes,  the  refuse  of  the 
olive  after  the  oil  is  expressed,  and  other  like  matters. 

The  warm  skins  of  animals  just  dead,  particularly  that  of  the  sheep, 
wrapped  around  the  body  of  the  patient,  with  the  wool  side  outwards, 
have  in  the  opinion  of  some  produced  good  results;  the  celebrated 
Marshal  Lannes,  Due  de  Montebello,  being  treated  in  this  manner 
after  a severe  injury  he  received  by  a fall  from  his  horse. 


LOCAL  BATHS. 


105 


Local  Baths.  The  Douse  or  Douche  Bath. — We  must  place  at  the 
head  of  local  baths  the  douse,  which  is,  perhaps,  more  frequently  em- 
ployed in  surgical  practice  than  most  any  other  form  of  local  bathing 
whatever.  It  consists  in  directing  a stream  of  water  upon  some  part 
of  the  body,  and  it  depends  for  its  efficacy  upon  the  temperature  of 
the  water  and  the  volume  and  height  of  the  stream. 

Passing  rapidly  over  the  surface,  the  particles  of  the  water  are 
always  cool,  and  thus  it  becomes  a most  powerful  refrigerant,  while 
the  percussion  and  the  weight  of  the  water  actively  stimulate  the 
capillaries. 

The  douse  may  be  either  cold  or  warm,  its  stimulating,  refrigerant, 
and  tonic  qualities  diminishing  with  the  increase  of  temperature.  The 
warm  douse  may  be  borne  as  high  as  180°  Fahr.,  but  it  is  seldom 
employed.  Its  stimulating  effects  are  direct,  and  not,  like  those  of 
the  cold  douse,  the  result  of  a reaction  subsequent  to  a primary  seda- 
tion. 

The  douse,  affording  as  it  does  a wide  range  of  temperature  from 
33°  to  180°  Fahr.,  is  applicable  to  the  treatment  of  numerous  diseases. 
In  chronic  affections  of  the  joints  it  enjoys  a high  reputation,  the 
diseased  part  being  subject  to  the  current  for  fifteen  or  twenty  minutes 
three  or  four  times  a day. 

As  a tonic  in  general  debility  it  is  also  valuable;  the  patient,  if 
very  weak,  may  begin  with  a more  elevated  temperature,  and  subse- 
quently reduce  it  to  40°  or  thereabouts. 

Paralysis,  not  depending  upon  acute  disease  of  the  brain,  may  also 
be  benefited.  Although  the  douse  has  been  recommended  in  the  acute 
phlegmasiae,  yet  great  caution  should  be  observed  in  its  administra- 
tion, lest  more  injury  be  done  than  good  conferred.  Chronic  headache, 
and  several  species  of  neuralgia,  especially  sciatica,  have  yielded  to  its 
influence. 

Old  glandular  swellings,  and  old  ulcers  verging  towards  the  class 
of  the  opprobria  medicorum,  have  sometimes  happily  given  way  to  its 
persevering  use. 

In  weak  eyes,  and  in  some  of  their  inflammatory  diseases,  Beer 
employed  a special  apparatus  for  applying  the  douse  to  the  eye.  It 
consists  of  a double  tin  vessel,  the  outer  one  for  containing  the  ice  to 
cool  the  water  contained  in  the  inner  compartment ; from  the  bottom 
of  the  latter  a long  tube  projects,  with  its  inferior  extremity  bent  back 
upon  itself,  and  drawn  out  to  a small  orifice  from  which  the  water 
falls  upon  the  diseased  eye. 

Gfraefe  used  for  the  same  purpose  a common  siphon,  with  its  short 
leg  immersed  in  water  contained  in  a vessel,  while  the  extremity  of 
the  long  limb  has  a gutta-percha  collar  fitted  to  it,  by  means  of  which 
nozzles  of  any  calibre  may  be  attached  to  the  tube,  to  direct  the  stream 
of  water  in  any  direction. 

Formerly  the  douse  was  much  used  in  the  treatment  of  mania,  and 
it  is  stated  that  a column  of  water  twelve  feet  high,  allowed  to  fall 
vertically  upon  the  head,  produces  such  intensely  painful  sensations 
that  the  most  furious  maniac  who  has  once  experienced  its  effects  will 
be  awed  by  the  mere  threat  of  its  application. 


106 


INJECTIONS. 


Fig.  66. 


The  Hqo-batli  (coxseluvium)  is  a powerful  derivative  remedy  in 
diseases  of  the  organs  contained  in  the  abdominal  and  pelvic  cavities 
and  the  lower  portion  of  the  spine,  and  may  be 
had  recourse  to  in  cases  where  general  bathing 
might  be  contraindicated  in  consequence  of  disease 
of  some  of  the  great  vessels  or  interior  organs;  it 
is  also  beneficial  in  strangury  and  prolapsus  ani, 
in  the  latter  case  the  addition  to  the  water  of  some 
astringent  substance  would  be  advantageous. 

The  vessel  used  for  applying  the  hip-bath  is 
seen  in  the  figure  (Fig.  66). 

The  Foot-bath  (pediluvium)  is  also  used  as  a 
revulsive  and  counter-irritant  in  catarrhs  and  de- 
terminations of  the  blood  to  the  head. 

The  water  should  be  as  hot  as  the  patient  can  bear  without  pain, 
and  made  more  stimulating  yet,  if  it  is  desirable,  by  the  addition  of 
mustard,  a quarter  of  a pound  of  cayenne  pepper,  or  a handful  of  salt. 

Twenty  minutes  will  be  a sufficiently  long  time  for  the  feet  and  legs 
to  be  immersed  in  the  water.  The  bath  should  be  taken  while  the 
patient  is  in  bed,  with  his  feet  hanging  over  its  edge;  or,  if  he  is 
sitting  up,  his  person  should  be  protected  by  a blanket. 

Other  local  baths  have  been  recommended,  which  are  only  limited 
in  number  by  the  different  parts  of  the  body  to  which  they  can  be 
applied.  They  are  of  real  utility  in  many  cases;  for  instance,  in  those 
persons  who  have  a tendency  to  free  and  distressing  perspiration  from 
the  axillae,  hands  or  feet,  or  other  parts  of  the  body,  water,  as  hot  as 
can  be  borne,  will  relieve  the  annoyance  to  a considerable  extent. 


CHAPTER  V. 

INJECTIONS. 

Injection  is  the  operation  by  which,  with  an  instrument  called  a 
syringe,  we  are  enabled  to  bring  fluids  of  various  kinds  in  contact 
with  the  internal  walls  of  the  different  canals  and  cavities,  whether 
natural  or  artificial,  of  the  human  body;  the  fluid  iujected  also  bears 
the  same  name.  Injections  are  exceedingly  numerous  and  varied, 
according  to  the  character  and  locality  of  the  cavity  to  be  injected,  as 
well  as  the  nature  of  the  fluids  employed. 

Simple  tepid  or  cold  water  is  often  used  to  wash  out  pus  or  other 
secretions  from  the  irregular  passages  produced  by  suppurative  action 
or  wounds,  and  where  other  means  could  not  be  used  at  all,  or,  at 
least,  would  be  painful  or  pernicious  to  the  delicate  granulations. 

The  injected  fluid  is  either  simple  water  of  various  degrees  of  tem- 
perature, according  to  circumstances,  or  water  medicated  with  emol- 
lient, narcotic,  astringent,  or  irritative  substances.  We  shall  now 
consider  the  various  kinds  and  methods  of  injection. 


INJECTIONS  OF  THE  EAR. 


107 


Injection  of  the  Lachrymal  Duct.  — This  injection  may  be 
accomplished  from  above  downwards,  through  the  puncta,  or  from 
below  upwards,  through  the  lower  orifice  of  the  nasal  duct,  termi- 
nating beneath  the  inferior  turbinated  bone. 

The  injection  can  be  thrown  through  either  of  the  puncta,  though 
the  inferior  one  is  to  be  preferred.  The  operation  is  thus  conducted : 
the  patient  is  seated  in  a chair,  with  his  head  supported  upon  the 
breast  of  an  assistant ; then  the  surgeon,  with  the  syringe  of  Anel 


Fig.  67. 


(Fig.  67)  held  in  his  right  hand,  places  its  point  into  the  orifice  of  the 
lower  punctum,  and  holds  it  there  a moment  lightly,  in  order  to  avoid 
producing  spasm  of  the  canaliculus,  which  might  occur  from  its  too 
sudden  introduction ; he  then  gently  passes  it  on  to  the  depth  of  an 
eighth  of  an  inch,  when  the  contents  of  the  syringe  must  be  discharged 
without  force,  as  the  fluid  ought  to  reach  the  sac  with  ease,  if  the 
syringe  is  properly  introduced,  and  there  be  no  obstruction  in  the 
canaliculus.  While  the  injection  is  being  accomplished,  the  eyelid 
should  be  permitted  to  assume  its  own  position. 

If  any  trouble  is  encountered,  the  introduction  of  one  of  Anel’s 
probes  will  be  advisable  before  the  syringe  is  tried  again.  The  injec- 
tion will  be  required  to  be  made  through  the  superior  punctum  if  the 
inferior  is  obliterated  or  obstructed. 

The  injection  from  below  is  accomplished  in  the  following  manner: 
The  patient  being  placed  in  the  same  position  as  in  the  previous  case, 
the  surgeon  takes  one  of  the  catheters  of  Grensoul  in  his  right  hand, 
with  its  convexity  upwards,  and  its  point  looking  downwards  and 
outwards,  and  passes  it  into  the  inferior  meatus  to  the  depth  of  little 
more  than  an  inch,  when  he  should  draw  the  catheter  gently  forwards, 
with  its  beak  pressing  gently  upon  the  outer  wall  of  the  meatus,  until 
it  is  arrested  by  catching  in  the  inferior  orifice  of  the  nasal  duct, 
when  he  suddenly  depresses  the  outer  extremity  of  the  instrument. 
The  syringe  may  then  be  fitted  to  the  catheter,  and  the  injection  made. 
AVhen  it  is  necessary  to  wash  the  parts  beneath  the  eyelids,  a syringe 
with  a little  bulbous  extremity  may  be  had  recourse  to. 

Injections  of  the  Ear. — For  the  purpose  of  cleansing  the  ex- 
ternal meatus  with  water,  a syringe  (Fig.  68)  of  about  the  capacity  of 
four  ounces  is  commonly  used.  It  is  provided  with  a smooth,  slender, 


108 


INJECTIONS. 


cylindrical  nozzle,  well  rounded  or  bulbous  at  its  point  that  the  deli- 
cate membrane  lining  that  canal  may  not  be  injured;  at  the  base  of 
the  syringe  there  are  two  rings,  one  upon  each  side,  by  which  the 
instrument  is  held,  the  thumb  and  ring  finger  being  passed  through 
them.  Another  ring  surmounts  the  piston  rod  to  receive  the  index 
finger,  by  the  aid  of  which  the  syringe  is  worked. 


Fig.  68. 


Toynbee’s  syringe  and  nozzle. 


The  fluid  to  be  injected  is  contained  in  a basin  held  beneath  the 
patient’s  ear ; this  also  serves  the  purpose  of  catching  the  water  as  it 

runs  away  from  the  meatus.  To  insure 
the  clothes  of  the  patient  from  being  wetted, 
it  will  be  desirable  to  fasten,  with  a piece 
of  wire,  beneath  the  lobule  of  the  ear,  a 
tin  or  pasteboard  gutter,  which  will  run 
the  water  clear  from  the  person  (Fig.  69). 

In  some  inflammatory  affections  of  the 
meatus  the  parts  become  exquisitely  pain- 
ful and  sensitive,  so  that  even  with  the 
greatest  care  more  or  less  suffering  will  be 
inflicted  in  performing  this  operation  and 
this  results  in  part  from  the  size  and  weight 
of  the  syringe  not  permitting  it  to  partici- 
pate in  the  motions  of  the  patient’s  head 
when  he  flinches  from  pain  or  is  disturbed 

in  the  habit  of  using  a convenient  little 
instrument  which  consists  of  a nozzle  an  inch  and  a half  long  with  a 
ring  fastened  to  its  outer  extremity,  and  connected  with  the  ordinary 
elastic-ball  pump. 

The  mode  of  employing  it  is  simply  to  seize  the  ring  of  the  nozzle 
between  the  thumb  and  index  finger  of  the  left  hand,  and  to  introduce 
it  into  the  meatus,  while  the  corresponding  forearm  rests  upon  the 
top  of  the  patient’s  head,  and  maintains  it  steady.  Then  with  the 
India-rubber  ball  in  the  right  hand,  a stream  of  water  may  be  continu- 
ously thrown  into  the  meatus  and  the  injection  completed  without 
removing  the  nozzle.  This  is  certainly  a great  advantage,  as  it  is 
well  known  that  not  the  least  painful  part  of  this  operation,  as  ordi- 
narily performed,  is  the  frequent  introduction  of  the  syringe,  a measure 
absolutely  indispensable,  in  a majority  of  cases,  to  obtain  a sufficiency 


in  any  way.  To  rid  myself  of  the  incon- 
veniences of  the  syringe.  I have  long  been 


Fig.  69. 


the  head. 


INJECTION  OF  THE  URETHRA. 


109 


of  water  to  insure  the  thorough  cleansing  of  the  meatus  or  the  dis- 
lodgment  of  a foreign  body. 

Injection  of  the  Urethra. — Medicated  solutions  are  introduced 
into  the  urethra  by  means  of  the  little  instrument  called  the  penis- 
syringe  ; it  is  manufactured  of  glass  or  metal,  the  former  being  pre- 
ferable, as  more  cleanly  and  free  from  the  corroding  effects  of  those 
active  chemical  agents  which  often  enter  into  the  composition  of  these 
injections.  The  capacity  of  the  syringe  should  not  be  more  than  one 
ounce,  as  this  quantity  of  fluid  will  be  amply  sufficient  to  fill  the 
entire  canal,  from  the  meatus  to  the  bladder. 

In  performing  the  operation  the  patient  may  either  stand  upright 
against  a wall  or  sit  upon  the  edge  of  the  bed  or  chair,  with  the  peri- 
neum well  thrown  forwards,  that  no  pressure  may  be  exercised  upon  it 
so  as  to  prevent  the  free  access  of  the  injection  to  the  deepest  part  of 
the  urethra.  The  syringe,  held  in  the  right  hand,  may  then  have  its 
nozzle  introduced  into  the  meatus,  while  pressure  should  be  made 
upon  the  glans  with  the  thumb  and  index  finger  of  the  left  hand,  to 
sustain  it  against  the  shoulder  of  the  instrument,  and  thereby  prevent 
the  egress  of  any  of  the  injected  fluid. 

The  piston  of  the  syringe  must  be  pressed  down  slowly,  as  the 
sudden  and  forcible  entrance  of  the  liquid  is  apt  to  excite  spasmodic 
action  of  the  canal,  and  cause  a good  deal  of  pain.  There  is  no  danger 
of  the  injection  passing  into  the  bladder,  as  some  patients  fear,  and,  in 
their  anxiety  to  prevent  it,  press  upon  the  perineum  during  the 
operation. 

Some  surgeons  recommend  that  a long  curved  catheter,  with  an 
olive-shaped  point  pierced  with  small  holes,  be  used  in  connection 
with  the  syringe,  in  order  to  bring  the  solution  with  certainty  in  con- 
tact with  the  deeper  parts  of  the  urethra;  there  are  diseases  of  its 
membranous  portion  which  cannot  be  reached  with  the  penis-syringe, 
and  such  an  instrument  as  seen  in  Fig.  70  is  required.  The  time  that 

Fig.  70. 


The  catheter-syringe. 

the  solution  should  be  permitted  to  remain  in  the  urethra  will  depend 
upon  its  strength;  in  ordinary  cases  three  or  four  minutes  will  gene- 
rally suffice.  The  operation  may  be  repeated  three  or  four  times  a day. 

In  this  manner  solutions  of  the  nitrate  of  silver,  sulphates  of  zinc 
and  copper,  alum,  tannin,  and  a host  of  other  remedies  may  be  used 
in  the  treatment  of  the  diseases  of  the  urethra.  The  usual  forms  of 
injections  will  be  seen  from  the  following  formulae : — - 

It- — Argent,  nitratis  crystal,  gr.  x ; 

Aquae  f^j.  M.  ft.  inject. 

Used  in  the  abortive  treatment  of  gonorrhoea.  (Acton.) 


110 


INJECTIONS. 


— Ziuci  sulph., 

Acid,  tannici,  aa  gr.  ij  ; 

Aquae  f§ij.  M.  ft.  inject. 

Used  in  gleet.  (Acton.) 

B- — Ferri  proto-iodidi  gr.  ij  ; 

Aquae  destillat.  f^viij.  M.  et  ft.  inject. 

Used  in  gonorrhoea.  (Bicord.) 

E. — Plumbi  acetatis  Qij ; 

Aquae  rosarum  fjjv.  M.  ft.  inject. 

Used  in  gonorrhoea.  (Eicord.) 

Injection  into  the  Bladder. — "We  have  already  considered  the 
subject  of  irrigation  of  the  bladder  with  the  double-tubed  catheter,  and 
but  few  words  are,  therefore,  necessary  under  this  heading.  For  the 
introduction  of  medicated  liquids  into  the  bladder,  a simple  catheter 
is  all  that  is  necessary ; this  with  a small  syringe  fitted  to  its  orifice 
will  enable  the  practitioner  to  bring  in  contact  with  the  vesical  mucous 
membrane  any  medicament  he  may  choose. 

It  should  be  borne  in  mind  that  when  this  organ  is  inflamed  and 
irritable  the  quantity  of  the  injected  fluid  should  be  small,  so  as  not 
to  provoke  violent  contractions,  and  thereby  cause  its  immediate 
rejection. 

The  diseases  in  which  these  injections  have  been  used  are  cystitis 
and  calculous  affections.  Dr.  Hoskins,  of  England,  employed  the 
saccharate  of  lead  for  dissolving  phosphatic  calculi ; Dr.  Eutherford 
used  lime-water ; Dr.  Eitter,  caustic  potassa ; Sir  B.  Brodie,  nitric 
acid ; and  other  surgeons,  simple  water,  or  a solution  of  bicarbonate  of 
soda.  Hone  of  these  trials  have,  however,  as  yet,  been  crowned  with 
sufficient  success  to  justify  the  retention  of  the  plan  as  a surgical 
resource  of  any  importance.  The  two  following  formulae  will  illus- 
trate the  manner  in  which  remedial  agents  are  sometimes  combined 
for  these  purposes : — 

B- — Argenti  nitratis  Jij ; 

Aquae  destillat.  f§iv.  M.  ft.  inject. 

Used  in  cystorrhoea.  (Acton.) 

B- — Sodae  bicarb.  Biijss  ; 

Saponis  alb.  §iss ; 

Aquae  destillat.  fjiv.  M.  ft.  inject. 

Used  in  certain  calculous  diseases.  (Bouchardat.) 

Injection  of  the  Vagina. — Besides  the  plan  of  irrigating  the 
vaginal  mucous  membrane  already  described,  it  is  sometimes  necessary 
to  have  recourse  to  another  one,  which  consists  in  bringing  in  contact 
with  this  membrane  solutions  of  considerable  medicinal  activity.  The 
operation  is  performed  with  an  instrument  called  the  female  syringe, 
which  is  cylindrical,  rounded  at  its  point  and  perforated  with  a number 
of  small  holes,  and  made  either  of  glass  or  metal,  of  a capacity  ordi- 
narily of  two  or  three  ounces. 

To  make  the  injection,  the  patient  should  be  placed  upon  her  back, 
with  the  hips  raised  upon  a pillow  and  the  thighs  elevated  and 
drawn  up;  then  two  or  three  syringefuls  of  the  fluid  ought  to  be 


INJECTION  OF  THE  UTERUS. 


Ill 


thrown  into  the  vagina  to  wash  away  any  adhering  mucosities  or 
other  discharges,  when  the  third  syringeful  may  be  introduced  and 
retained  there  three  to  five  minutes,  by  means  of  a napkin  pressed 
against  the  vulva. 

The  diseases  in  which  these  injections  are  employed  are  gonorrhoea, 
leucorrhoea,  and  various  vaginal  discharges. 

Professor  Simpson  has  attracted  the  attention  of  the  profession  to 
another  valuable  mode  of  applying  local  remedies  to  the  vaginal  mu- 
cous membrane,  which  consists  in  the  combination  of  certain  remedies 
with  lard  and  was,  and  giving  them  the  form  of  suppositories.  They 
bear  the  name  of  medicated  pessaries.  The  following  formulae  will 
indicate  the  manner  in  which  these  are  prepared : — 

R. — Zinci  oxidi  gr.  xv  ; 

Cerae  albae  gr.  xv  ; 

Axungise  3iss.  M.  f.  pess. 

R. — Plumbi  acetat.  gr.  vij ; 

Cerae  albae  gr.  xxij  ; 

Axungise  3iss.  M.  f.  pess. 

R . — Ung.  hydrarg.  fort,  £ss  ; 

Cerse  flavse  3ss ; 

Axungise  5i*  M.  f.  pess. 

R. — Plumbi  iodidi  gr.  vj  ; 

Cerae  Havas  5SS  i 

Axungise  gr.  lxx.  M.  f.  pess. 

R. — Tanninse  gr.  x ; 

Cerse  albse  gr.  xxv ; 

Axungise  giss.  M.  f.  pess. 

R. — Extr.  beliadonnse  gr.  x; 

Cerae  flavae  gr.  xxiv. 

Axungiae  3iss.  M.  f.  pess. 

These  pessaries  are  used  in  various  painful  and  inflammatory  dis- 
eases of  the  vagina  and  the  adjacent  organs.  (Simpson.) 

R. — Zinci  sulphatis, 

Aluminis  calc.,  aa  3hss  '> 

Aquae  destillat.  Oj.  M.  f.  inject. 

Used  in  leucorrhoea.  (Pringle.) 

Injection  of  the  Uterus. — Injections  of  various  fluids  into  the 
uterine  cavity  have  been  performed  in  some  cases  with  considerable 
advantage,  but  the  operation  is  a delicate  one,  and  requires  circum- 
spection, lest  injury  imperilling  life  be  done  to  that  viscus.  The  in- 
strument with  which  it  may  be  effected  is  a common  syringe,  holding 
about  an  ounce,  and  mounted  with  a stem  about  the  size  of  a No.  6 
catheter,  and  nine  inches  long. 

The  patient  may  be  conveniently  placed  in  the  same  position  as  for 
vaginal  injection,  and  the  practitioner  having  introduced  his  left  fore- 
finger up  to  the  os  uteri,  the  stem  of  the  syringe  is  passed  into  the 
uterine  cavity  upon  this  as  a guide. 

The  quantity  of  fluid  injected  at  one  time  should  never  exceed  an 
ounce,  and,  in  order  to  be  on  the  safe  side,  one-half  or  a quarter  of 
this  amount  may  be  tried  at  first. 

In  violent  uterine  hemorrhage  it  has  been  recommended  to  inject 
cold  water  into  that  cavity.  This  can  be  best  accomplished  by  a 
common  straight  catheter  and  the  elastic  ball  pump. 


11  2 


INJECTIONS. 


Vidal  de  Cassis  employed  in  several  chronic  uterine  diseases  an 
injection  of  a decoction  of  the  dried  leaves  of  the  black  walnut. 

Injection  of  the  Rectum,  or  Enemata. — When  injections  are 
made  in  the  rectum  they  are  variously  denominated  glysters,  clysters, 
enemata,  or  lavements. 

There  are  numerous  forms  of  the  instrument  for  performing  this 
operation : the  common  enema  syringe,  now  falling  into  disuse  since 
the  introduction  of  India-rubber  syringes  constructed  upon  the  prin- 
ciple of  the  force-pump,  consists  of  a white  metal  cylinder,  provided 
with  nozzles  of  different  lengths  and  curvatures,  which  may  be 
attached  or  detached  at  pleasure,  so  as  to  enable  the  attendant  or 
the  patient  himself  to  make  the  injection  either  just  within  the  sphinc- 
ter, or  to  a greater  distance  up  the  bowel.  This  syringe  varies  in 
size,  holding  from  two  to  sixteen  ounces  or  more.  The  inconvenience 
attending  the  use  of  this  instrument  by  the  patient  can  readily  be 
appreciated,  and  the  great  improvement  over  this  of  the  clyster  pumps, 
of  which  there  is  an  exceeding  variety  ; but  none  of  them  are  so  sim- 
ple in  construction  or  effective  as  that  manufactured  of  India-rubber. 
This  consists  of  an  oval  ball  of  rubber  with  two  flexible  tubes  attached 
to  it,  one  at  each  of  its  extremities;  at  the  base  of  each  of  these  there 
is  placed  a ball  valve,  opening  in  the  direction  of  the  nozzle. 

The  instrument  is  used  by  introducing  the  pipe  into  the  rectum,  while 

the  other  end  of  the  tube  is 
put  into  a basin ; and  then,  bv 
alternately  pressing  upon  and 
relaxing  the  hold  on  the  ball, 
the  water  is  sucked  up  and 
forced  into  the  rectum. 

In  hot  climates  these  tubes 
become  soft  and  get  out  of 
order,  so  that  under  these  cir- 
cumstances a metallic  instru- 
ment is  to  be  preferred ; and 
perhaps  the  best  of  this  kind  is 
that  manufactured  by  Messrs. 
Maw  and  Son,  of  London,  and 
seen  in  Fig.  71. 

Dr.  J.  Y.  Totherick  has  pro- 
posed an  enema  tube  which  he 
believes  combines  cheapness, 
simplicity,  and  efficiency  in  no 
ordinary  degree.  “ The  appa- 
ratus consists  simply  of  five  or  six  feet  of  three-eighths  inch  India- 
rubber  tubing,  to  one  end  of  which  is  fixed  an  ordinary  funnel  capa- 
ble of  holding  a sufficient  quantity  of  fluid,  and  to  the  other  end  one 
of  the  common  ivory  insertion  pipes.  The  method  of  using  it  is  as 
follows : first,  fill  the  funnel  with  the  liquid  to  be  emp^ed.  whilst 
holding  the  exit  pipe  at  the  same  level ; secondly,  squeeze  with  the 
finger  and  thumb  the  end  of  the  pipe  to  which  the  ivory  is  attached, 
to  prevent  premature  exit  of  the  fluid  ; thirdly,  insert  the  ivory  exit 


Fig.  71. 


INJECTION"  OF  THE  RECTUM,  OR  ENEMATA. 


113 


pipe  into  the  rectum  ; fourthly,  elevate  the  funnel  to  the  length  of  the 
tube,  and  allow  hydrostatic  pressure  to  force  in  the  injection.” 

Whichever  kind  of  instrument  is  employed,  it  is  important  that 
their  nozzles  or  pipes  be  smooth,  cylindrical,  and  well  rounded,  or 
bulbous  at  the  extremity,  in  order  that  the  rectal  walls  be  not  per- 
forated or  torn,  an  accident  which  has  happened,  the  fluid  being  thrown 
into  the  cavity  of  the  peritoneum,  or  into  the  cellular  tissue  of  the 
pelvis,  producing  in  the  former  case  a fatal  peritonitis,  and  in  the 
latter  tedious  and  almost  always  fatal  pelvic  abscess. 

In  administering  an  enema,  the  patient  may  lie  upon  either  side, 
with  the  leg  which  is  uppermost  somewhat  flexed : then,  if  the  old 
form  of  a syringe  is  used,  having  well  oiled  its  nozzle,  the  surgeon 
gently  insinuates  his  left  forefinger,  oiled,  into  the  anus,  and  upon  this 
as  a director  passes  the  point  of  the  instrument  into  the  rectum.  The 
left  hand  should  then  hold  the  head  of  the  syringe  firmly  and  steadily, 
while  the  piston  is  being  slowly  forced  down  with  the  right. 

In  some  cases  the  great  irritability  of  the  gut  causes  the  sphincter 
to  contract  forcibly ; but  no  violence  should  be  used  to  overcome  this, 
as  the  gradual  pressure  of  the  pulp  of  the  finger  will  vanquish  the 
resistance  in  a few  moments. 

The  curved  form  of  the  rectum  should  always  be  borne  in  mind, 
that  the  proper  direction  may  be  given  to  the  syringe  in  its  introduc- 
tion, which  should  be  first  upwards  towards  the  umbilicus,  then  back- 
wards and  upwards,  after  it  has  penetrated  to  the  depth  of  an  inch,  in 
the  curve  of  the  sacrum,  inclining  the  nozzle  a little  to  the  left. 

As  to  the  quantity  of  the  injection,  this  will  depend  upon  the  object 
in  view.  If  that  be  simply  to  evacuate  the  intestine,  the  enema  should 
be  large,  twelve  to  sixteen  ounces;  and  to  insure  the  fluid’s  remaining 
there  a sufficiently  long  time  to  soften  the  fecal  matters,  it  must  be 
gradually  forced  from  the  syringe,  to  give  the  intestine  an  opportunity 
to  adapt  itself  to  the  newly-added  bulk.  From  not  attending  to  this 
point  an  injection  may  fail  in  bringing  away  the  fecal  contents  of  the 
rectum,  which  contracts  quickly  and  strongly  under  the  stimulus  of 
a distension  suddenly  established.  On  the  other  hand,  when  some 
medicament  is  intended  either  to  exercise  a local  and  continuous  action 
upon  the  mucous  membrane,  or  to  affect  the  system  by  absorption, 
the  quantity  should  be  moderate,  from  one  to  three  ounces.  Thus  an 
efficient  anodyne  is  an  injection  of  an  ounce  of  mucilage  containing 
twenty  or  thirty  drops  of  the  tincture  of  opium. 

By  reason  of  the  large  number  of  veins  about  the  rectal  walls,  absorp- 
tion takes  place  rapidly,  and  therefore  we  can  obtain  a more  decided 
impression  upon  the  system  in  this  manner  with  an  equal  quantity  of 
opium  than  when  it  is  given  in  the  usual  way  by  the  mouth.  Cubebs, 
quinia,  and  other  remedies  may  be  administered  in  the  same  manner. 

A patient  may  be  kept  alive  several  weeks  by  nutritive  injections 
alone,  such  as  broths,  soups,  solutions  of  gelatine,  and  albumen.  But 
none  of  these  articles  can  supply  the  absorbents  with  those  elements 
taken  up  by  them  from  food  which  has  passed  through  the  intestinal 
canal  and  become  thoroughly  impregnated  with  its  secretions,  so  that 
beyond  the  period  stated  a person  must  inevitably  perish  unless  other 


114 


INJECTION'S. 


sustenance  be  introduced  into  the  stomach.  It  has  been  suggested 
that  the  addition  of  pepsine  to  these  injections  may  contribute  in  some 
degree  to  give  them  the  character  of  digested  food. 

Hard  lumps  of  stercoraceous  matter  or  hemorrhoidal  tumors  may  pre- 
vent the  fluid  from  passing  into  the  bowel,  or,  as  O'Byrne  has  shown, 
feces  may  collect  in  the  sigmoid  flexure  of  the  colon,  beyond  which 
the  ordinary  clyster  pipe  could  not  throw  the  injection  : in  such  cases 
as  these  a long  tube,  such  as  is  found  in  connection  with  the  stomach 
pump,  must  be  introduced  above  the  point  of  obstruction,  and  the 
enema  injected  through  this.  With  care  a flexible  tube  two  feet  long- 
can  be  passed  into  the  colon. 

In  constipation,  with  a relaxed  condition  of  the  mucous  membrane 
of  the  bowel,  injections  of  cold  water,  either  alone  or  with  the  addition 
of  a tablespoonful  of  common  table  salt,  a little  molasses,  or  a quantity 
of  soapsuds,  will  give  great  relief  to  the  patient,  and  suffice  to  secure 
the  discharge  of  a normal  quantity  of  feces  daily.  In  some  cases, 
again,  warm  water  will  be  found  preferable  to  cold. 

When  a powerful  action  is  desired  to  be  exercised,  an  injection 
containing  the  oil  of  turpentine  may  be  had  recourse  to;  such  a one 
will  be  found  in  the  ordinary  purgative  enema  of  the  Pharmacopoeia. 

In  chronic  diarrhoea  and  dysentery,  injections  of  solutions  of  the 
nitrate  of  silver,  terchloride  of  iron,  and  the  sulphates  of  copper  and 
zinc  may  often  be  advantageously  used. 

It  should  not  be  forgotten  that  in  employing  large  enemata  the 
rectum  may  be  distended  to  such  a degree  as  to  paralyze  its  contractile 
power  so  that  the  fluid  will  not  be  passed  until  a tube  is  inserted  into 
the  anus  for  that  purpose. 

The  too  frequent  use  of  injections  and  suppositories  may  favor,  or 
even  induce  hemorrhoids,  or  some  organic  change  of  the  rectum. 

• Suppositories  are  composed  of  some  fatty  matter  or  other  adhesive 
material  incorporated  with  any  remedial  agent.  The  common  purga- 
tive suppository  is  a piece  of  brown  soap  cut  into  a cylindrical  shape 
and  of  suitable  size  to  be  introduced  beyond  the  sphincter ; catharsis 
results  from  its  irritating  the  lower  portion  of  the  rectum. 

If  the  aim  of  the  practitioner  is  to  introduce  a medicament  into  the 
circulation,  it  should  be  reduced  to  powder  and  brought  to  the  proper 
consistence  with  lard  or  butter,  and  then  moulded  into  an  ovoid  mass. 

The  suppository  can  be  most  conveniently  placed  in  its  proper  posi- 
tion by  means  of  a small  glass  syringe,  which  resembles  a penis  syringe 
with  its  nozzle  cut  olf  and  the  margins  of  the  glass  well  rounded,  so 
that  the  sphincter  may  not  be  wounded. 

The  following  are  common  forms  of  prescription  for  enemata  and 
suppositories : — 

It- — 01.  olivse  f^j  ; 

Magnes.  sulph.  §ss ; 

Saccliar.  alb.  §j  ; 

Sennse  §ss  ; 

Aquae  bullientis  f^xvj. 

Infuse  tlie  senna  for  an  hour  in  the  water  ; then  dissolve  the  salt  and  sugar : add 
the  oil,  and  mix  them  by  agitation.  {Ed.  Pharm.) 

A laxative  enema. 


INJECTION  INTO  THE  CELLULAR  TISSUE. 


115 


R. — Sodii  chloridi  §ss  ; 

Adipis  Jj  ; 

Fseeis  sacckar.  f§j ; 

Aquse  fervent.  Oj.  M.  f.  enema. 

This  is  the  mild  laxative  enema  of  domestic  practice. 

R. — Extract,  colocyntliid.  5SS  ! 

Saponis  mollis  gj  ; 

Aquae  Oj. 

Mix  and  rub  them  together.  {Land.  Pharm.) 

A powerful  purgative  injection  in  colic  and  constipation. 

R. — Tinct.  opii  rtlxxx  ; 

Decoct,  amyli  fjiv. 

Mix  them.  ( Land . Pharm.) 

This  enema  is  used  in  strangury,  obstinate  vomiting,  diarrhoea, 
dysentery,  and  in  painful  diseases  of  the  kidneys  and  bladder. 

R. — 01.  terebinth.  f§j  ; 

Vitelli  ovi  No.  j ; 

Decoct,  hordei  fgxix. 

Rub  the  oil  with  the  yelk,  and  mix  the  decoction  with  them.  ( Land . Pharm.) 

A stimulating  purgative  enema. 

R.— Aloes  9ij  ; 

Potass,  carb.  gr.  xv  ; 

Decoct,  hordei  Oss. 

Mix,  and  rub  them  together.  (£7.  S.  Pharm.) 

This  enema  is  employed  in  amenorrhcea  attended  with  constipation, 
and  ascarides. 

R. — Assafoetidse  prep.  Rj ; 

Decoct,  hordei  Oss. 

Rub  the  assafetida  with  the  decoction  gradually  added,  till  they  are  thoroughly 
mixed.  (Loud.  Pharm.) 

This  is  gently  laxative,  carminative,  and  antispasmodic. 

R. — Aloes, 

Sodii  chloridi,  aa  gr.  xv  ; 

Mellis  q.  s.  M.  f.  suppos. 

An  active  purgative  suppository. 

R. — Pulv.  opii  gr.  § ; 

Butyrei  gijss.  M.  f.  suppos. 

An  anodyne  suppository. 

R. — Quiniee  gr.  xv  ; 

Butyrei  giss.  M.  f.  suppos. 

An  antiperiodic  suppository  when  the  stomach  will  not  bear  the 
quinine.  (Boudin.) 

Injection  into  the  Cellular  Tissue  (hypodermic  injection). — 
This  is  a practice  which  has  only  been  introduced  within  the  last  few 
years,  and  during  that  time  the  repeated  experience  of  the  profession 
has  sustained  it  as  a very  valuable  means  in  the  treatment  of  obsti- 
nate cases  of  neuralgia  and  many  other  painful  diseases.  The  same 
plan  has  also  been  suggested  for  the  purpose  of  bringing  in  contact 
with  the  interior  structure  of  tumors,  and  other  morbid  growths, 
various  irritating  and  caustic  agents,  to  destroy  them  either  by  their 
direct  chemical  action  or  the  succeeding  inflammation. 


116 


INJECTIONS. 


Fig.  72 


The  hypodermic  injection  is  effected  with  a small  syringe  of  glass 
or  gutta  percha  (Fig.  72),  armed  with  a long,  hollow,  needle- 
like nozzle  for  perforating  the  skin.  It  is  intended  to  hold 
about  one  drachm,  and  the  piston-rod  is  graduated,  that  the 
dose  may  be  accurately  determined. 

The  operation  is  easy ; the  practitioner  pinches  up  with 
the  fingers  of  the  left  hand  a fold  of  the  skin,  and  with  his 
right  enters  the  point  of  the  syringe  into  its  base,  either  by 
a rotatory  movement  or  a quick  stab.  When  the  puncture 
is  accomplished,  the  skin  must  be  permitted  to  resume  its 
normal  position,  when  the  fluid  must  be  slowly  thrown  from 
the  instrument  by  pressing  down  the  piston. 

Annoying  abscesses  in  the  cellular  tissue  often  succeed  to 
this  little  operation,  and  is  about  the  only  unpleasant  acci- 
dent attending  it. 

Absorption  of  the  fluid  occurs  rapidly,  and  if  it  contains 
an  anodyne  in  solution,  its  action  is  soon  manifested  upon 
the  system  by  a marked  alleviation  of  the  pain. 

The  narcotic  solution  usually  employed  consists  of  an 
ounce  of  water  containing  a grain  of  morphia  ; of  this  one 
drachm  should  be  introduced  twice  a day.  The  alkaloids 
— aconitine  and  atropia— may  also  be  employed  in  solution 
in  the  doses  of  one-thirtieth  to  one-fortieth  of  a grain. 

It  has  been  proposed  to  destroy  cancerous  tumors  by 
thrusting  the  needle  of  the  hypodermic  syringe  an  inch  or 
more  into  their  substance,  and  throw  into  it  thirty  to  fifty 
minims  of  dilute  acetic  acid,  one  part  of  the  acid  to  two  of 
water.  The  suggester  of  this  plan,  Dr.  W.  H.  Broadbent, 
of  London,  states  that  his  aim  had  been  not  necrosis  of 
malignant  tumors,  but  a modification  in  tlieir  nutrition. 
The  theoretical  grounds  for  this  hope  were,  that  cancer 
owed  its  malignancy  to  its  cellular  or  (to  use  a nomencla- 
ture now  almost  antiquated)  foetal  structure ; and  that  in 
acetic  acid  we  had  an  agent  which  might  be  expected  to 
diffuse  itself  through  the  tumor  and  reach  the  cells,  and, 
having  reached  them,  to  effect  changes  in  their  structure, 
and  affect  them  vitally,  while  it  could  scarcely  do  harm.” 
Injection  of  Abnormal  Canals. — Long  and  sinuous 
passages  running  under  the  skin  and  among  the  deeper 
tissues  may  often  be  traced  out,  and  solutions  of  various 
medicaments  brought  in  contact  with  their  walls. 

The  syringe  which  I employ  for  this  purpose  has  a capacity  of 
about  two  ounces,  is  made  of  glass,  and  supplied  with  a number  of 
hollow,  flexible  stems  of  soft  lead  eight  inches  long,  and  of  various 
sizes,  each  capable  of  being  attached  or  detached  from  the  syringe  at 
pleasure. 

The  operation  consists  in  introducing  these  metallic  tubes,  bent 
into  the  proper  shape,  into  the  sinus,  and  injecting  the  fluid  against 
any  desired  point;  or  it  may  be  distributed  along  the  entire  course 
of  the  canal. 


PURIFICATION  OF  AIR  IN  HOSPITALS  AMD  CHAMBERS.  117 


CHAPTER  VI. 

ON  THE  USE  OF  GASES  AND  VAPORS. 

In  this  chapter  it  will  be  our  object  to  consider  the  various  methods 
in  which  certain  vapors  and  gases  are  used  by  the  profession  as  reme- 
dial agents  in  the  cure  and  prevention  of  disease. 

Some  of  these  agents  are  applied  to  the  exterior  of  the  body,  either 
to  its  whole  extent  or  to  a limited  portion  of  it.  In  the  first  instance 
the  operation  is  called  general,  and  in  the  latter  local  fumigation.  The 
application  of  other  agents  is  restricted  to  the  bronchial  mucous  mem- 
brane, and  constitutes  what  is  technically  known  as  inhalation ; while 
a third  class  embraces  those  articles  which  are  disseminated  in  the  air 
with  a view  of  purifying  it,  or  destroying  any  noxious  effluvia  that 
may  be  contained  therein,  and  become  the  cause  of  disease.  When 
these  vaporous  agents  act  chemically  upon  the  morbific  constituents 
of  impure  air — that  is,  destroying  them  by  forming  new  and  inert 
compounds — they  receive  the  name  of  disinfectants;  while  those  which 
simply  mask  unpleasant  odors  are  termed  deodorants.  Of  the  first 
kind  we  may  mention,  as  a good  type  of  the  whole  class,  chlorine, 
which  disinfects  by  combining  with  the  hydrogen  of  sulphuretted 
hydrogen  and  its  compounds ; of  the  second  kind,  the  vapor  of  vine- 
gar and  eau  de  cologne  diffused  through  tbe  air  of  the  sick-chamber 
may  be  instanced. 


SECTION  I. 

PURIFICATION  OF  THE  AIR  OF  HOSPITALS  AND  CHAMBERS,  OR  DISINFECTION. 

The  subject  of  disinfection  is  one  of  the  greatest  importance  to  the 
medical  practitioner,  and  demands  a close  investigation  as  to  the  real 
extent  of  its  usefulness,  and  how  far  it  may  be  relied  upon  as  accom- 
plishing the  object  for  which  it  is  employed. 

There  can  be  no  doubt  that  in  a widely-spread  epidemic  its  influ- 
ence is  very  slight,  if  at  all  appreciable,  and  is  far  inferior,  as  a pre- 
ventive means,  to  other  sanitary  measures,  especially  cleanliness. 
Thousands  of  experiments  with  the  various  reputed  disinfectants,  ex- 
tending over  a space  of  time  of  more  than  a century,  have  been  made 
in  many  parts  of  the  South  of  Europe  in  numerous  and  fatal  epidem- 
ics ; and  the  conclusions  from  them  seem  to  be,  as  stated  above,  that 
little  or  no  reliance  can  be  placed  upon  this  class  of  agents. 

The  atmosphere  may  be  rendered  impure  by  such  gases  as  carbonic 
acid,  sulphuretted  hydrogen,  nitrogen,  &c.,  which  analysis  makes 
known,  and  chemistry  suggests  and  supplies  the  appropriate  agents 
to  destroy  them ; but,  unfortunately,  in  a majority  of  cases  such  a 
strictly  scientific  course  cannot  be  pursued,  for  the  reason  that  the 


118 


ON  THE  USE  OF  GASES  AND  VAPOES. 


presence  and  nature  of  most  morbific  causes  diffused  in  the  atmo- 
sphere have  as  yet  remained  undiscovered  by  any  chemical  tests,  how- 
ever delicate.  Such,  for  instance,  are  the  contagious  principles  of  the 
exanthematous  fevers,  hospital  gangrene,  and  typhus  fever;  hence, 
the  use  of  disinfectants  in  such  cases  is  based  upon  purely  empirical 
practice. 

These  abnormal  elements  in  the  air  have  been  variously  termed 
emanations,  miasms,  malaria,  and  fomites — names  that  are  simply 
used  to  designate  phenomena  of  which  we  are  altogether  ignorant. 

Some  of  the  simpler  cases  of  atmospheric  impurity  arise  from  well- 
determined  causes,  as  a diminution  of  the  natural  proportion  of  oxygen 
in  the  air  surrounding  vats  where  the  acetous  fermentation  is  taking 
place.  In  this  instance,  the  only  remedy  is  to  remove  the  cause. 
Carbonic  acid  is  largely  liberated  under  the  same  circumstances,  and 
also  from  plants  during  the  night ; it  is  found  in  wells  and  caves 
originating  from  the  decomposition  of  the  surrounding  soil.  Quick- 
lime and  lime-water  are  the  proper  corrective  agents  in  these  cases,  as 
they  will  absorb  carbonic  acid  to  a considerable  extent.  Dupuytren 
long  ago  suggested  the  plan  of  lighting  two  fires,  one  above  the  other, 
in  the  mouths  of  old  wells,  to  displace  the  carbonic  acid  by  the  strong 
current  of  air  thereby  produced.  The  custom  of  lowering  burning 
braziers  into  wells  is  based  upon  the  same  principle. 

In  the  neighborhood  of  sinks  and  latrines,  sulphuretted  hydrogen, 
hydrosulphate  of  ammonia,  and  nitrogen,  are  found  diffused  through 
the  air,  and  may  be  destroyed  by  chlorine,  or  the  nitrate  of  lead 
(Ledoyen’s  Disinfecting  Fluid,  composed  of  eight  ounces  of  the  nitrate 
dissolved  in  a gallon  of  water),  the  former  decomposing  them  by  ab- 
stracting their  hydrogen,  and  the  latter,  their  sulphur : the  resulting 
compound,  in  the  first  instance,  being  chlorohydric  acid,  and,  in  the 
second,  the  sulphide  of  lead. 

Various  other  disinfectants  are  sometimes  employed  with  a view  of 
decomposing  or  destroying  those  atmospheric  poisons  upon  which 
many  contagious  and  epidemic  diseases  are  supposed  to  depend.  As 
stated  before,  their  use  in  such  cases  is  purely  empirical,  and  their 
asserted  efficacy  very  doubtful. 

Chlorine  and  its  compounds  are  had  recourse  to,  perhaps  oftener 
than  any  other  article,  for  this  purpose.  The  chlorine  may  be  obtained 
very  easily  from  a mixture  containing  one  ounce  of  the  black  oxide 
of  manganese,  three  ounces  of  common  salt,  one  fluidounce  of  sulphuric 
acid,  and  two  fluidounces  of  water.  These  materials  must  be  placed 
in  a saucer  or  other  like  vessel ; a number  of  these  saucers  thus  pre- 
pared may  be  put  at  intervals  in  the  wards  of  a hospital  or  other 
apartment  to  be  disinfected.  The  same  result  may  be  obtained  by 
using  the  chlorinated  lime  in  dishes,  or  sprinkling  Labarraque’s  Solu- 
tion'— the  Liquor  Sodee  Qhlorinatse  of  the  Pharmacopoeia — upon  the 
floor  and  upon  the  bedclothes  of  the  patients.  In  either  case  a suffi- 
cient quantity  of  the  chlorine  should  be  developed  to  produce  a 
decided  odor  of  that  gas,  and  never  enough  to  cause  irritation  of  the 
bronchial  tubes. 

I have  employed,  as  a means  of  purifying  infected  ships,  a mixed 


PURIFICATION  OF  AIR  IN  HOSPITALS  AND  CHAMBERS.  119 

gas  of  chlorine  and  hydrochloric  acid,  obtained  by  burning  chloroform 
and  alcohol  together  in  the  proportion  of  two  parts  of  the  former  to 
one  of  the  latter.  The  mixture  is  placed  in  a shallow  saucer,  and  a 
piece  of  cotton  cloth  immersed  in  it  to  serve  the  purpose  of  a wick. 
When  a lighted  candle  is  applied  to  a projecting  end  of  the  cloth  it 
takes  fire,  and  the  chloroform  burns  with  a dense  black  smoke,  very 
irritating  to  the  conjunctiva  and  the  bronchia.  For  this  reason  it 
could  not  be  used  in  apartments  where  the  sick  are  lodged,  but  for 
purifying  empty  hospital  wards  or  a ship,  nothing  can  be  better 
than  this.  The  plan  I usually  adopted  was  to  set  fire  to  several 
dishes  of  the  mixture,  placed  at  different  points  in  the  apartment,  and 
then  close  up  all  the  windows,  doors,  and  hatches  for  three  or  four 
hours.  After  which  everything  is  again  thrown  open  to  permit  the 
free  circulation  of  fresh  air. 

Chlorine  was  first  employed  as  a disinfectant  in  France  upon  the 
strength  of  a statement  made  by  the  celebrated  chemist  Guyton  de 
Morveau,  that  it  possessed  the  power  of  destroying  all  animal  miasms. 
About  the  same  time,  Smith,  in  England,  brought  forward  nitrous 
acid  gas  as  a disinfectant,  which  shared  the  great  reputation  of  chlorine 
as  an  agent  for  the  same  purpose.  The  nitrous  acid  gas  may  be  ob- 
tained by  heating  together  in  a saucer,  placed  upon  a sand-bath,  four 
drachms  of  nitrate  of  potassa  and  two  fluidrachms  of  fluoric  acid. 

Ozone  has  also  had  its  share  of  praise  as  a purifier  of  infected  air. 
Dr.  Moffat,  in  a paper  read  before  the  British  Association,  in  1862, 
stated  that  he  had  employed  phosphorus  for  obtaining  ozone,  and 
had  found  it  a valuable  disinfectant  during  its  luminous  state,  which 
he  discovered  to  be  much  influenced  by  certain  atmospheric  conditions; 
a high  pressure,  low  temperature,  and  the  wind  from  the  northern 
points  of  the  compass  being  the  conditions  of  its  non-luminosity,  and 
the  reverse  ones  those  of  its  luminosity.  He  describes  his  plan  of 
using  phosphorus  in  the  following  manner : “ I take  a quart  bottle 
with  a wide  mouth,  into  which  I put  rather  more  than  half  a pint  of 
water;  a piece  of  cork  carrying  a flat  piece  of  phosphorus  with  a 
clean  cut  surface,  floats  upon  the  water.  The  mouth  of  the  bottle 
is  loosely  covered  with  a card.  The  bottle  is  then  placed  first  in  one 
part,  and  then  in  another  of  the  apartment  to  be  purified,  until  the 
peculiar  smell  of  ozone  is  detected,  or  until  my  test-papers  indicate  1 
of  my  ozone  scale.  The  process  of  purifying  may  be  performed  night 
and  morning,  or  oftener.  For  purifying  air  in  the  neighborhood  of 
street  gratings  or  in  sewers,  I simply  suspend  a piece  of  phosphorus 
from  the  grating.  In  apartments  the  temperature  may  be  sufficiently 
high  to  keep  phosphorus  luminous  under  all  atmospheric  conditions; 
but  in  sewers  it  will  be  luminous  or  non-luminous,  according  to  the 
height  of  the  barometer,  the  temperature  of  the  surrounding  air,  and 
the  direction  of  the  wind,  and  ozone  will  be  produced  only  when  it  is 
luminous.” 

The  vapor  of  iodine  has  been  tried  in  England,  with  a certain 
amount  of  success,  diffused  through  the  air  of  the  sick  chamber. 
According  to  Righini  it  possesses  remarkable  antiseptic  and  anti- 
spasmodic  properties,  and  is  a valuable  hygienic  resource  in  hospitals. 


120 


ON  THE  USE  OF  GASES  AND  VAPORS. 


He  recommends  that  it  be  employed  in  the  following  manner:  A soft 
paste  is  made  by  moderately  heating  sixteen  parts  of  starch  in  a 
sufficient  quantity  of  distilled  water,  and  stirring  them  with  a wooden 
spatula.  Eight  parts  of  iodoform  having  been  added,  the  mixture 
will  be  found  to  be  readily  absorbed  by  filtering-paper.  The  paper 
prepared  in  this  way  is  cut  into  strips  three  or  four  inches  wide,  and 
suspended  in  the  wards.  The  iodoform  slowly  escapes  without  causing 
any  inconvenience  to  the  inmates.  It  is  most  freely  liberated  in  moist 
states  of  the  atmosphere.  M.  ftighini  recommends  iodoform  paper 
for  the  purpose  of  obviating  the  bad  smells  and  noxious  effluvia  of 
slaughter  houses,  and  also  for  preserving  meat  from  spoiling. 

Sir  William  Burnet’s  disinfecting  fluid  is  a solution  of  the  chloride 
of  zinc  in  water,  in  the  proportion  of  twenty-five  grains  to  one  fluid- 
ounce.  In  using  it,  one  pint  of  the  fluid  may  be  mixed  with  five  gal- 
lons of  water.  Its  power  is  limited  to  the  decomposition  of  sulphu- 
retted hydrogen  and  hydrosulphate  of  ammonia. 

The  permanganate  of  potassa  is  a valuable  disinfectant,  acting  by 
decomposing  the  noxious  gases;  it  is  itself  insipid  and  inodorous, 
which  is  a further  commendation  of  this  truly  efficient  agent  in 
surgical  practice.  It  may  be  employed  either  in  solution  or  in  powder 
mixed  with  starch  or  carbonate  of  lime;  a few  applications  of  the 
remedy  to  grayish-colored  and  fetid  ulcers,  or  gangrenous  wounds, 
will  entirely  remove  the  bad  smell  and  restore  a roseate  color  to  the 
diseased  tissues.  Injections  of  the  permanganate  may  be  made  in 
cancerous  affections  of  the  uterus,  and  in  chronic  ulcerations  of  the 
mucous  membrane  of  the  nasal  fossae,  with  advantage. 

Sulphurous  acid  gas  was  very  anciently  employed  as  a disinfectant, 
and  is  mentioned  by  Homer.  It  may  be  obtained  by  burning  sulphur 
in  an  open  vessel,  or  by  applying  heat  to  a mixture  of  mercury  and 
sulphuric  acid  contained  in  a retort.  MM.  Kurz  and  Manuel  recom- 
mended that  the  streets  of  Paris  should  be  fumigated  with  the 
sulphurous  acid  gas  during  a malignant  and  widely  spread  epidemic 
of  cholera. 

The  bisulphite  of  soda  and  the  sulphite  of  soda  and  lime  enjoy  similar 
properties  with  the  sulphurous  acid. 

Cheap  disinfectants  for  throwing  into  latrines  and  for  covering  up 
masses  of  decaying  animal  and  vegetable  matters,  will  be  found  in 
common  quicklime,  and  the  powder  of  MM.  Corne  and  Demeau, 
which  consists  of  100  parts  of  sulphate  of  lime  and  three  parts  of 
coal-tar. 

Carbon,  in  the  form  of  smoke,  is  often  used  by  sailors  to  disinfect 
ships ; its  efficacy  is  materially  enhanced  by  the  presence  of  a small 
quantity  of  creasote,  which  is  always  present  among  the  products  of 
the  combustion  of  wood. 

We  cannot  properly  consider  the  explosion  of  gunpowder  and  the 
making  of  large  fires  in  infected  localities  as  possessing  disinfecting 
properties.  They  can  act  in  no  other  way  than  by  causing  a move- 
ment or  circulation  of  the  air,  from  which  little  assistance  could  be 
expected  under  any  other  circumstances  than  dislodging  carbonic 


PURIFICATION  OF  AIR  IN  HOSPITALS  OR  CHAMBERS.  121 


acid  or  other  gaseous  agents  from  wells  or  excavations.  M.  Balcels, 
a chemist  of  Barcelona,  suggested  that  cinnabar  and  the  oxide  of 
arsenic  be  added  to  the  gunpowder  before  explosion. 

The  vapors  of  vinegar,  acetic  acid,  camphor,  and  the  resins  should 
rather  be  regarded  as  deodorants  than  as  disinfectants. 

For  the  purpose  of  purifying  the  garments  of  the  sick,  the  Hebrews 
depended  largely  upon  the  copious  use  of  fresh  water,  and  doubtless 
this  agent,  unassisted,  will  suffice  in  many  cases;  but  the  operation 
will  be  very  much  more  certain  and  speedy  in  all  cases  by  the  use 
of  steam  at  200°  or  even  higher.  Dry  heat  will  answer  the  same 
purpose,  but  it  is  apt  to  damage  the  texture  of  the  clothes. 

When  water  is  employed  in  cleansing  infected  wearing-apparel  and 
bedclothes,  the  addition  to  it  of  lime-water  or  the  solutions  of  the 
bisulphite  or  hypochlorite  of  soda  will  facilitate  the  acquisition  of  the 
object  in  view. 

M.  Balcels  had  recourse  first  to  a solution  of  the  pernitrate  of  mer- 
cury in  water,  in  the  proportion  of  one  part  of  the  former  to  seventy 
parts  of  the  latter,  and  then  fumigated  the  clothes  with  chlorohydric 
acid  gas. 

Disinfection  naturally  includes  the  action  of  antiseptics,  and  the 
latter,  therefore,  need  a passing  notice.  The  antiseptic  most  frequently 
employed  in  hospital  gangrene  and  sloughing  sores  or  wounds  is  the 
permanganate  of  potassa  in  solution,  in  the  proportion  of  five  parts  to 
fifteen  parts  of  water. 

A piece  of  fine  linen  wrung  out  of  a solution  of  the  chloride  of 
soda  (Labarraque’s  solution),  and  laid  over  the  parts,  will  correct  the 
fetor  of  profusely  suppurating  wounds. 

Bromine  has  been  much  used,  of  late,  for  the  purpose  of  arresting 
the  progress  of  hospital  gangrene,  and  is  considered  an  effective  agent. 
It  may  be  applied  with  a camel’s-hair  brush. 

Carbolic  acid,  an  oily  liquid  obtained  by  distilling  coal  tar  and 
quicklime  together,  resembles  creasote  in  its  antiseptic  properties, 
contracting  and  hardening  the  animal  tissues,  and  protecting  them 
from  putrefaction. 

A concentrated  solution  of  the  bisulphite  of  soda,  injected  into  the 
arteries,  will  preserve  a subject  from  decomposition  six  or  eight  weeks 
in  the  warmest  weather. 

Ammonia,  in  the  form  of  vapor,  possesses  antiseptic  power  to  a 
considerable  extent;  it  acts  catalytically,  by  preventing  oxygen  com- 
bining with  oxidizable  matters.  In  employing  this  agent  for  the 
preservation  of  organic  substances,  it  is  important  to  exclude  all  other 
antiseptics  before  or  during  the  time  the  specimen  is  being  exposed 
to  the  vapor.  The  only  apparatus  needed  is  a simple  jar,  in  which 
the  substance  to  be  preserved  is  suspended,  having  previously  intro- 
duced into  it  about  a drachm  of  strong  liquid  ammonia;  then  render 
the  jar  hermetical  by  a luting  of  soap  or  a mixture  of  soap  and  red 
lead.  For  the  preservation  of  fluids,  ammonia  may  be  added  to  them 
in  the  proportion  of  ten  to  twenty  minims  to  the  ounce. 

Cleanliness,  both  of  the  apartments  and  the  clothes  and  person  of 


122 


OK  THE  USE  OF  GASES  AND  VAPORS. 


tlie  sick,  will  do  more  towards  preventing  the  rise  and  progress  of 
disease  than  any  amount  of  disinfection. 

The  rooms  in  which  the  sick  and  wounded  are  lodged  should  he 
scrupulously  cleansed;  the  floors  well  scrubbed,  but  "never  flooded 
with  water,  as  is  sometimes  done,  particularly  in  the  “sick  bays”  of 
our  men-of-war.  The  simplest  plan  to  avoid  this  is  “dry  scrubbing,” 
which  consists  in  using  a brush  and  sand  only,  and  subsequently 
sweeping  the  floor  with  a broom ; or,  again,  the  scrubber  may  use  a 
brush  and  hot  water,  drying  apace  as  he  proceeds.  The  walls  should  be 
covered  with  whitewash,  which,  though  it  may  not  act  as  an  absorbent 
of  pernicious  miasms,  as  some  have  supposed,  will,  nevertheless,  be 
advantageous  by  keeping  them  clean,  and  diffusing  around  a feeling 
of  cheerfulness. 

All  vessels  containing  slops,  soiled  dressings,  and  offensive  dis- 
charges ought  to  be  removed  at  once  from  the  room,  and  a free  circu- 
lation of  air  kept  up  in  it.  This  maybe  accomplished  by  opening  the 
windows  and  doors  in  summer;  in  winter,  a fire  built  in  the  chimney- 
place  will  cause  a current  from  the  crevices  of  the  doors  towards  the 
fire  and  up  the  chimney. 

On  board  of  ships,  ventilation  is  a matter  of  the  greatest  moment 
to  the  health  of  the  crew,  who  are  usually  crowded  during  the  night 
into  a very  restricted  space;  and  were  it  not  for  the  numerous  hatches 
almost  always  kept  open,  serious  consequences  to  the  health  of  the 
men  would  certainly  result.  In  the  construction  of  the  English  hos- 
pitals and  barracks,  1200  cubic  feet  of  breathing  space  is  allotted  each 
man,  which  is  far  greater  than  the  allowance  in  our  war  vessels,  aboard 
of  which,  by  an  injudicious  system  of  bulkheads,  but  one  person,  the 
captain,  of  the  whole  complement  has,  during  sleep,  a sufficiency  of 
that  health-sustaining  element,  pure  air. 

For  the  purpose  of  ventilating  the  apartments  below  decks,  air- 
chimneys,  or  windsails,  as  they  are  called,  are  used,  and  sometimes 
specially  constructed  machines,  such  as  the  ventilators  of  Hales,  Briu- 
dejonc,  and  Souchou. 

The  figure  from  Fonssagrive  ( Traite  Hygiene  Xavale)  shows  the  ven- 
tilator of  Brindejonc  (which  is  one  of  the  best),  by  which  the  foul  air 
of  apartments  either  in  hospitals  or  in  ships,  may  be  driven  out.  It 
consists  of  a cylinder  25  inches  in  height,  having  two  parallel  bases 
of  3 feet  3 inches  in  diameter.  One  of  these  bases  is  provided  with 
a toothed  wheel  of  12  inches  in  diameter,  having  fifty-two  teeth,  and 
supporting  at  its  centre  a crank ; this  wheel  turns,  when  it  is  in 
motion,  a little  cog  armed  with  thirteen  teeth,  and  to  the  centre  of 
which  is  fixed  a stem  with  the  four  wings  of  the  ventilator.  Tbe 
other  base  has  at  its  middle  a circular  opening  of  11  inches,  traversed 
diametrically  by  a small  iron  bar  which  is  used  as  a point  d'oppui  to 
the  axis.  Upon  one  of  the  points  of  the  circumference  of  the  cylinder 
there  is  an  elliptical  opening,  having  191  inches  in  its  transverse  dia- 
meter, and  11  inches  in  its  vertical  axis,  through  which  the  air  comes 
out.  The  ventilator  is  arranged  with  four  wings,  cutting  each  other 
at  right  angles.  When  the  toothed  'wheel  is  put  in  motion  by  the 
crank,  it  catches  upon  the  little  pinion,  and  turns  the  wings  rapidly; 


APPLICATION  OF  VAPORS  AND  GASES  TO  SKIN.  123 


the  air  is  introduced  through,  the  circular  opening  at  the  base,  and 
issues  forcibly  from  the  elliptical  opening  upon  the  side  of  the 
cylinder. 


Fig.  73. 


Brindej  one’s  ventilator. 

In  connecting  the  machine  with  the  air  of  apartments  and  that 
externally,  we  employ  stiff  cylindrical  pipes  made  of  canvas,  and  of 
the  necessary  length. 

With  a small  five-horse  power  steam-engine,  25,000  cubic  feet  of 
fresh  air,  heated  to  an  appropriate  temperature,  can  be  driven  per 
minute  through  the  wards  of  the  largest  hospital,  and  in  all  our  steam 
war  vessels  this  plan  should  be  adopted,  particularly  in  those  cruising 
in  hot  latitudes.  It  has  been  found  efficient  in  the  iron  clads,-  and 
quite  as  great  a necessity  exists  for  a good  system  of  ventilation  in 
other  classes  of  vessels. 


SECTION  II. 

THE  APPLICATION  OF  VAPORS  AND  GASES  TO  THE  SKIN. 

1.  Fumigation. — We  have  already  described  the  manner  of  apply- 
ing aqueous  vapor  to  the  skin,  under  the  heading  of  vapor  bath,  and 
we  have,  therefore,  nothing  further  to  say  of  it  in  this  place. 

Other  vapors  are  also  used,  either  dry  or  moist ; their  action,  like 
the  aqueous  vapor,  partly  depends  upon  their  heat,  humidity,  and 
density,  but  in  general  they  also  possess  some  special  therapeutical 
activity,  either  locally  or  being  absorbed  generally ; in  the  latter  case 
the  whole  system  is  more  or  less  influenced  by  them.  Thus  the  vapor 
of  water  may  be  rendered  more  emollient  by  the  addition  of  some  bland 
substances,  such  as  marshmallow;  or,  what  is  more  often  the  case, 
stimulating  and  alterative  by  combining  it  with  the  vapors  of  alcohol 
or  the  mineral  acids.  Sulphur,  the  volatile  oils,  camphor,  benzoic 
acid,  the  resins,  and  gum  resins  are  volatilized  by  throwing  them  upon 
hot  metallic  plates  placed  beneath  an  apparatus  by  which  the  patient  is 


124 


ON  THE  USE  OF  GASES  AND  VAPORS. 


surrounded ; they  have  an  action  similar  to  that  of  the  preceding 
medicaments. 

Of  the  articles  absorbed  into  the  circulation,  the  most  frequently 
employed  are  the  compounds  of  mercury,  and  their  use  by  fumigation 
in  the  East  Indies  dates  back  to  a very  remote  period.  . They  are 
still  much  used  by  the  native  practitioners  in  the  treatment  of  obsti- 
nate skin  diseases  and  syphilis.  In  skin  disease,  the  quantity  of  the 
sulphide  of  mercury,  of  cinnabar,  of  black  oxide,  or  of  the  common 
mercurial  ointment  employed  at  one  fumigation,  is  from  a half  to  three 
drachms,  and  of  sulphur  half  an  ounce  volatilized  upon  a hot  iron 
plate  placed  beneath  a blanket  supported  on  hoops  and  surrounding 
the  patient’s  person.  If  he  is  out  of  bed,  a common  box  or  hogshead, 
•with  a hole  cut  into  it  for  the  head  to  be  protruded  that  the  vapors 
may  not  be  breathed,  will  answer  the  same  purpose. 

A higher  temperature  of  a dry  gas  may  be  more  easily  borne  than 
a lower  one  of  a humid  gas,  for  in  the  latter  case  the  transpiration 
will  be  arrested,  and  the  patient  will,  therefore,  suffer  greatty  from  a 
sensation  of  internal  heat  and  oppression,  and  soon  become  exhausted. 
The  difference  in  the  action  of  moist  and  dry  gas  is  shown  in  the 
experiments  of  Drs.  Fordyce  and  Blagden  upon  heated  air,  bv  which 
it  was  demonstrated  that  a man  might  remain  some  time  in  an  oven 
with  a dry  air  heated  to  350°  ; while  air  of  the  same  temperature  cou- 
t"\  taining  aqueous  vapor  could  not  be  borne. 

The  classes  of  cases  in  which  fumigation  is  employed  are  chronic 
rheumatisms,  syphilitic  affections,  and  inveterate  skin  diseases. 

Sometimes  the  application  of  the  vapor  is  limited  to  restricted  por- 
tions of  the  body  by  means  of  boxes  of  a sufficient  size  to  surround 
them.  In  this  way,  chronic  inflammations  of  the  joints,  periostitis, 
and  ulcers  have  been  treated.  M.  Dumarquay  has  succeeded  in  re- 
lieving pain,  in  checking  fetid  secretions,  and  sometimes  in  healing 
ulcers,  by  surrounding  the  parts  with  an  atmosphere  of  carbonic  acid. 

2.  The  Application  of  Hot  Air  to  Wounds. — M.  Jules  Guyot 
suggested  the  unique  method  of  treating  wounds  by  immersing  them 
in  an  atmosphere  of  heated  air,  and  which  he  designated  as  the  method 
of  curing  wounds  by  “ incubation”  (par  incubation).  The  plan  is 
founded  upon  the  observations  of  surgeons  in  hot  climates,  that  wounds 
healed  more  quickly  under  an  elevated  temperature  than  the  reverse. 
This  is  strikingly  illustrated  in  the  influence  of  our  high  summer  heats 
over  the  adhesive  process,  which  takes  place  much  more  surely  than 
in  cold  weather  and  damp  cool  latitudes.  The  same  thing  is  observed 
in  the  constitution  of  the  Arab,  whose  climate,  active  habits,  and  diet 
produce  a spare  and  sinewy  frame  and  a sort  of  dry  temperament  very 
favorable  for  the  quick  healing  of  wounds.  I have  made  the  same 
observation  in  some  parts  of  the  East  Indies  where  the  population  is 
under  analogous  influences.  In  the  Gulf  of  Mexico  the  heat  during 
the  summer  is  excessive;  and  it  was  during  a period  of  this  sort  of 
weather  that  I received  into  the  hospital  under  my  charge,  at  the 
mouth  of  the  Mississippi  River,  a large  number  of  the  wounded  during 
the  naval  operations  against  New  Orleans.  Though  the  buildings 
were  crowded  with  the  wounded  and  fever  patients,  all  of  the  wounds 


APPLICATION  OF  HOT  AIR  TO  WOUNDS. 


125 


healed  with  unusual  rapidity  ; and  of  fifteen  cases  of  amputation  of  the 
thigh  and  arm  but  two  died,  both  of  them  after  secondary  operations, 
one  of  the  patients  having  lost  a good  deal  of  blood  from  having  his 
knee  shattered  by  a rifle  shot;  in  the  other  case,  disarticulation  was 
performed  at  the  shoulder  for  a gunshot  wound  of  both  the  axillary 
artery  and  vein. 

Eochard,  in  speaking  of  the  healing  of  wounds  in  hot  climates, 
says  : “All  of  our  confreres  point  out  the  rapidity  of  their  course  and 
the  promptitude  with  which  they  heal.  I have  myself  been  able  to 
verify  it  often  at  Madagascar.  The  bad  guns  of  which  the  Sacolares 
made  use  often  burst  in  their  hands,  and  I have  seen  some  of  these 
complicated  wounds,  for  which  I had  proposed  amputation,  heal  with 
a wonderful  facility,  in  spite  of  the  most  irrational  treatment.  Inter- 
tropical  climates  are  favorable  to  the  efforts  of  conservative  surgery  ; 
and  operations,  when  it  is  impossible  to  avoid  them,  succeed  better 
there  than  in  Europe.  The  same  observation  has  been  made  in 
Oceanica,  on  the  coast  of  Africa,  in  South  America,  and  in  the  Antilles. 
It  explains  the  almost  constant  success  of  the  amputations  of  naval 
surgeons  on  equatorial  stations,  and  the  remarkable  cures  that  they 
often  obtain  when  it  is  possible  to  abstain  from  them.” 

The  incubative  apparatus  of  Guyot  was  invented  for  the  purpose  of 
placing  wounds  under  these  identical  conditions  as  found  in  hot 
climates.  It  consists  of  an  oblong  box  about  fourteen  inches  long, 
twelve  inches  deep,  and  twelve  inches  wide,  with  its  extremities  open, 
and  having  tacked  around  the  margins  of  each  a piece  of  muslin  a 
foot  wide,  and  furnished  at  its  unattached  border  with  an  elastic  cord 
to  closely  embrace  the  limb.  The  lower  wall  of  the  box  is  double, 
the  upper  partition  dividing  the  box  into  two  parts,  an  upper  and 
larger  one  and  a lower  one ; these  communicate  with  each  other  by 
means  of  two  narrow  grooves  in  the  lateral  walls  of  the  box,  while  the 
smaller  compartment  is  connected  with  the  external  air  by  means  of 
an  elbow-tube,  under  the  external  extremity  of  which,  shaped  like  a 
funnel,  a spirit  lamp  is  to  be  placed.  The  upper  wall  of  the  box  must 
be  a glass  plate,  that  the  condition  of  the  inclosed  limb  may  be  always 
under  observation ; and  the  bulb  of  a small  thermometer  is  placed 
inside  the  box,  with  its  stem  projecting  exteriorly,  so  that  the  tempera- 
ture of  the  inclosed  air  can  be  ascertained  at  any  moment. 

The  apparatus  above  described  is  that  directed  for  wounds  of  the 
lower  extremities ; but  Guyot  proposes  a number  of  others,  constructed 
upon  the  same  principle,  to  be  used  for  the  arms,  shoulder,  hip,  and 
even  for  the  whole  body. 

The  wounded  part  must  be  inclosed  in  the  apparatus  in  such  a 
manner  that  the  movements  of  the  patient  or  the  involuntary  contrac- 
tions of  the  muscles  may  not  disturb  it,  or,  if  it  be  a stump,  pull  it 
from  the  box. 

Guyot,  in  his  practice,  sustained  the  air  within  the  box  at  about 
81°  Fahr.  M.  Eobert  employed  the  apparatus  extensively  in  the 
treatment  of  wounds,  ulcers,  and  a large  number  of  surgical  diseases; 
and  advised  that  in  recent  injuries  a period  of  twelve  hours  should  be 
permitted  to  elapse  before  applying  it. 


126 


ON  THE  USE  OF  GASES  AND  VAPORS. 


Velpeau  states  that  he  has  made  some  trials  with  the  apparatus  in 
his  department  in  the'  hospital  of  La  Charite,  but  they  have  been 
neither  sufficiently  numerous  nor  varied  to  allow  of  his  giving  an 
opinion  of  its  value. 

SECTION  III. 

THE  APPLICATION  OF  GASES,  VAPORS,  AND  ATOMIZED  LIQUIDS  TO  THE 
INTERIOR  CAVITIES. 

Inhalation. — The  simplest  method  of  influencing  the  bronchial 
mucous  membrane  by  vaporous  remedial  agents  is  to  diffuse  them 
through  the  atmosphere  of  the  patient’s  apartment ; in  this  manner  we 
use  burning  tar  and  paper  saturated  with  a solution  of  the  nitrate  of 
potassa.  It  has  been  proposed  to  conjoin  some  of  the  narcotics  with 
the  nitrate  of  potassa — for  instance,  belladonna,  stramonium,  digitalis, 
and  lobelia ; the  materials  may  be  mixed  with  paper  pulp,  and  moulded 
into  pieces  of  suitable  size,  one  of  which  may  be  burnt  in  the  chamber 
of  a patient,  in  the  evening,  during  an  asthmatic  paroxysm. 

Some,  again,  prefer  to  smoke  the  dried  leaves  of  the  stramonium 
plant  in  a pipe,  or  to  have  them  cut  fine  and  rolled  up  in  imitation  of 
cigarettes.  The  following  formula  will  show  how  the  cigarettes  may 
be  prepared : — 

ip — Fol.  belladonnse  gr.  iv  ; 

Fol.  stramonii, 

Fol.  liyoscyami,  aa  gr.  ij  ; 

Fol.  phellandiii  gr.  jss  ; 

Extr.  opii  gr.  £ ; 

Aquae  lauro-ceraci  q.  s. 

Dissolve  the  extract  of  opium  in  the  cherry-laurel  water,  and,  having  cut  the  leaves 
fine,  mix  them  with  the  solution,  and  roll  them  up  in  paper  also  previously  moistened 
with  the  laurel- water  and  dried.  (Jamain.) 

Two  or  three  of  these  cigarettes  may  be  smoked  each  day  during 
an  attack  of  nervous  asthma. 

Raspail  recommends  the  inhalation  of  the  vapor  of  camphor,  small 
fragments  of  which  may  be  placed  in  a quill  for  that  purpose ; it  is 
vaporized  by  the  warmth  of  the  palm  of  the  hand  in  which  it  is  held. 
He  says  it  relieves  catarrh,  obstinate  cough,  and  the  paroxysms  of 
asthma. 

Special  instruments,  called  inhalers,  are  sometimes  employed  for 
this  purpose,  an  old  form  of  which  is  that  designated  as  the  kludge 
inhaler,  consisting  of  a pewter  pot  with  a cover  to  which  a flexible 
tube  and  mouthpiece  are  attached ; but  a more  useful  and  convenient 
inhaler  may  be  easily  prepared  in  the  following  manner : Get  of  any 
tinner  a cylindrical  tin  vessel  about  ten  inches  high  and  three  and  a 
half  to  four  inches  in  diameter  ; iuside  of  this  have  another  tin  vessel, 
half  the  length  of  the  former,  fitted  and  resting  upon  its  edge  by  a 
narrow  rim ; three-quarters  of  an  inch  from  its  bottom  there  is  a pro- 
jecting ledge  to  support  a double  tubulated  glass  jar  to  contain  the 
fluid  to  be  inhaled.  One  of  the  tubulures  is  fitted  with  a cork  support- 
ing a glass  tube  to  permit  the  entrance  of  air  to  the  jar,  and  a slim  ; 
thermometer  to  indicate  the  temperature  of  its  interior ; to  the  other 


INHALATION. 


127 


Fig.  74. 


Fig.  75. 


tubulure  a flexible  tube  and  mouthpiece  are  attached,  through  which  the 
patient  inhales  the  vapor  from  the  interior  of  the  jar.  The  inner  tin 
vessel  contains  water,  and  serves  the  purpose  of  a water  bath,  being 
heated  by  a spiritdamp  placed  beneath  it,  through  a large  aperture 
cut  into  the  outer  vessel  near  its  bottom.  With  this  simple  inhaler 
any  volatile  substance  dissolved  in  water,  and  placed  within  the  glass 
jar,  may  be  brought  in  contact  with  the  bronchial  mucous  membrane. 

A still  less  expensive  inhaler  may  be  prepared,  represented  in  Figs. 
7-1,  75.  It  consists  of  a wide-mouth 
jar  fitted  with  a cork,  through  which 
two  glass  tubes  pass  to  the  interior 
of  the  vessel.  Through  the  bent 
tube  the  patient  inhales  the  vapor 
rising  from  the  liquid  in  the  jar, 
while  the  other  tube,  projecting  be- 
low the  fluid,  admits  the  air  from 
the  exterior. 

By  the  addition  of  geum,  marsh- 
mallow, slippery-elm  bark,  elder 
flowers,  &c.,  to  the  water,  emollient 
vapors  are  obtained,  which  are  very 
soothing  to  the  irritated  bronchial 
tubes;  a few  drops  of  any  of  the 
volatile  oils,  or  tincture  of  guaiacum, 
render  the  vapor  stimulating,  while  opium,  belladonna,  and  hyoscya- 
mus  confer  calmative  properties. 

A simple  plan  of  inhalation,  often  employed  in  domestic  practice, 
is  to  reverse  a funnel  over  the  vessel  containing  the  liquid,  and 
through  its  smaller  end  the  patient  draws  the  vapor,  by  placing  it  in 
his  mouth  and  making  deep  inspirations.  M.  Righini  states  that  the 
inhalation  of  iodoform  dissolved  in  ether  is  of  great  service  in  retard- 
ing the  progress  of  phthisis. 

A teaspoonful  of  chlorine  water  to  a pint  and  a half  of  water,  placed 
in  the  inhaler  and  respired  three  or  four  times  a day,  according  to  the 
tolerance  of  the  patient,  once  enjoyed  a high  reputation  in  the  treat- 
ment of  phthisis  and  other  pulmonary  diseases.  Sir  Charles  Scuda- 
more used,  as  he  thought  with  advantage,  in  similar  cases,  the  vapor  of 
iodine.  Indeed,  the  whole  class  of  volatile  medicines  has  been  tried 
from  time  to  time  in  the  treatment  of  the  various  affections  of  the 
lungs,  sometimes  with  advantage,  and  at  others  fruitlessly. 

The  idea  of  inhaling  oxygen  was  long  ago  spoken  of  by  Sir  Hum- 
phrey Davy,  and  in  1804  Dr.  Eddoes  had  conceived  the  propriety  and 
utility  of  the  same  method  of  medication.  Dr.  R.  H.  Goolden,  of 
London,  has  made  some  experiments  lately  with  this  agent,  and  adds 
his  testimony  to  its  advantages  in  phagedenic  ulceration  of  the  throat 
and  in  chronic  gout.  He  employed  a large  vulcanite  bag,  with  a tube, 
stopcock,  and  mouthpiece,  which  was  filled  with  a mixture  of  oxygen 
and  air  in  the  proportion  of  one  to  four.  The  gas  is  inhaled  by  the 
patient  and  expired  into  the  atmosphere.  The  administration  may 


128 


ON  THE  USE  OF  GASES  AND  VAPORS. 


be  made  for  half  an  hour  each  day,  the  gas  being  slowly  inspired  at 
intervals,  and  filling  the  lungs  as  much  as  possible. 

Inhalation  of  Atomized  Fluids.— More  recently,  a new  method 
of  inhalation  has  been  introduced  into  practice,  that  of  employing 
atomized  remedial  agents  in  the  treatment  of  thoracic  diseases. 
It  consists  in  substituting  for  vapor  solutions  of  certain  substances 
in  a finely-divided  state,  forming  a mist  or  spray.  This  novel  plan 
was  first  suggested  by  Sales- Girons,  in  1852,  and  since  that  time  has 
been  employed  by  physicians  both  in  Europe  and  America  with  decided 
success  in  relieving  and  curing  many  of  the  diseases  of  the  throat  and 
lungs.  In  fact  the  whole  system  may  be  affected  by  these  inhalations, 
as  sea-water  used  in  this  manner  seems  to  exercise  a decidedly  bene- 
ficial influence  on  scrofula,  particularly  as  it  occurs  in  young  subjects 
under  bad  hygienic  influences  in  large  cities. 

The  instrument  by  which  the  fluid  is  converted  into  spray  is  called 
an  atomizer,  the  simplest  form  of  which  is  seen  in  the  common  nur- 
sery tube,  which  consists  simply  of  two  glass  tubes  placed  at  right 
angles,  and  haviug  their  approximating  ends  drawn  out  in  small 
orifices ; the  tubes  are  supported  in  the  above  position  by  a metallic 
brace.  In  using  the  instrument  one  of  its  legs  is  immersed  in  fluid, 
and  the  person  blows  forcibly  through  the  other,  by  which  operation 


Fig.  7(3. 


Atomizer  of  Sales-Girons 


the  rapid  passage  of  the  air  through  the  horizontal  tube  over  the  open 
orifice  of  the  vertical  tube  produces  in  the  latter  a vacuum  which  the 


INHALATION  OF  ATOMIZED  FLUIDS. 


129 


fluid  in  the  cup  rises  to  fill,  and  finally  emerges  at  the  orifice  into 
the  stream  of  air,  and  is  there  broken  up  by  it  into  spray,  and  pro- 
jected from  the  instrument  some  distance,  according  to  the  strength 
of  the  current  of  air. 

As  the  operation  performed  in  this  manner  would  be  objectionable, 
both  on  account  of  the  fatigue  it  would  be  to  the  operator  as  well  as 
the  repugnance  the  patient  would  have  to  breathing  air  projected 
directly  from  another  person’s  lungs,  the  elastic  force  of  compressed 
air  or  of  steam  is  employed  for  this  purpose,  and  hence  the  use  of 
two  kinds  of  instruments.  Of  those  in  which  a rapid  current  of  com- 
pressed air  is  used,  the  instrument  (Fig.  76)  invented  by  M.  Sales- 
Girons  is  the  best,  and,  though  somewhat  complicated,  yet  it  works 
beautifully.  It  consists  of  a glass  jar,  A,  containing  an  air-pump,  which 
exercises  the  requisite  degree  of  pressure  upon  the  fluid  contained  in 
the  jar ; c is  the  manometer  for  indicating  the  degree  of  compression  ; 
D is  the  tube  through  which  the  fluid  escapes  to  pass  to  the  drum  g, 
inside  of  which  there  is  a little  metallic  disk,  placed  obliquely,  upon 
which  the  fluid  strikes,  to  be  atomized  and  then  thrown  by  the  drum 
towards  the  face  of  the  patient ; an  elastic  tube  is  put  below  the  drum 
with  an  expanded  end  above  to  catch  the  drops  of  fluid  which  escape 
from  the  drum,  and  to  carry  them  into  the  glass  below. 

The  steam  Atomizer,  Fig.  77,  consists  of  a small  copper  boiler  with 
a rectangular  tube  attached  to  it,  and  furnished  with  an  aperture  at  the 
top  through  which  the  water  for  making  steam  is  introduced ; this  is 

Fig.  77.  Fig.  78. 


Steam  atomizer. 

closed  with  a common  cork.  Along  side  of  this  is  a small  steam  valve 
designed  to  permit  the  escape  of  steam  when  the  interior  pressure  rises 
beyond  a certain  degree.  A small  glass  or  porcelain  cup  is  intended 
to  hold  the  fluid  to  be  atomized,  and  is  placed  so  that  the  vertical  tube 
may  be  immersed  in  it.  To  employ  the  instrument,  place  a spirit 
lamp  beneath  the  boiler  containing  water,  and  when  the  steam  beo-ins 
to  flow  through  the  horizontal  tube,  the  little  cup  with  its  contents 
must  be  put  beneath  the  vertical  limb,  and  imihediately  the  liquid 


130 


ON  THE  USE  OF  GASES  AND  VAPORS. 


will  rise  in  the  tube  and  become  atomized  in  the  current  of  steam. 
Fig.  78  shows  the  shield  to  protect  the  face  from  the  vapor. 

With  the  atomizer  any  substance  capable  of  solution  may  be  intro- 
duced into  the  lungs  in  the  form  of  a spray.  As  an  illustrative  example 

we  may  employ  carbolic  or  phe- 
nic  acid,  suggested  some  three 
years  since  by  that  eminent  phy- 
siologist Dr.  Longet  in  tubercu- 
losis, of  which  he  himself  was  a 
subject.  The  mode  of  admini- 
stration is  as  follows : fifteen 
drops  of  pure  acid  are  dissolved 
in  5ij  of'  alcohol,  and  the  solu- 
tion mixed  with  sxij  of  water. 
This  quantity  may  be  atomized 
and  inhaled  daily. 

Besides  the  bronchial  mucous 
membrane  it  is  proposed  also  to 
bring  the  spray  in  contact  with 
the  lining  membranes  of  the 
bladder,  the  vagina,  and  the  ute- 
rus with  specially  constructed 
instruments. 

M.  Dumarquay,  in  his  work 
on  pneumatology,  extols  the  ad- 
vantages of  the  introduction  of 
carbonic  acid  gas  into  the  blad- 
der in  diseases  of  the  genito- 
urinary organs,  such  as  cystitis 
and  vesical  neuralgia.  The  vesi- 
cal douche  may  be  easily  ad- 
ministered with  a small  caoutchouc  bag  filled  with  carbonic  acid, 
which  is  thrown  into  the  bladder  through  a common  catheter;  or 
Mondollot’s  apparatus  may  be  employed,  consisting  of  a double-tubed 
catheter  and  an  India-rubber  bag,  which  facilitates  the  escape  of  any 
gas  in  excess  in  the  bladder. 

The  same  author  has  also  derived  benefit  from  the  carbonic  acid 
douche  in  certain  uterine  affections — amenorrhoea,  dysmenorrhoea, 
chronic  enlargements,  and  simple  ulcerations  of  the  cervix. 

It  may  be  effected  with  the  apparatus  seen  in  Fig.  79,  which  con- 
sists of  a common  bottle  having  attached  to  its  mouth  an  elastic  tube 
about  three  feet  long,  provided  with  an  ivory,  nozzle. 

The  materials  to  be  introduced  into  the  bottle  for  generating  the 
gas  are  about  a tablespoonful  each  of  bicarbonate  of  soda  and  tartaric 
acid  with  six  ounces  of  water. 


Fig.  79. 


Apparatus  for  applying  carbonic  acid  gas  to  the 
uterus. 


PREPARATION  AND  APPLICATION  OF  BANDAGES.  131 


CHAPTER  VII. 

THE  “SECOND  PIECES”  OF  DRESSING,  OR  BANDAGES  PROPERLY 

SO  CALLED. 

We  have  already  described  the  “ first  pieces”  of  surgical  dressings, 
those  which  are  intended  for  immediate  contact  with  wounds.  Some- 
times they  are  the  only  dressings  employed  in  the  treatment  of  a 
case,  but  more  frequently  other  pieces  are  required  to  retain  them 
in  a proper  position  ; and  it  is  to  these  that  the  technical  term  “ second 
pieces”  has  been  applied,  or  simply  bandages. 

Bandages  are  of  three  kinds,  simple,  compound,  and  mechanical. 
Simple  bandages  are  formed  by  an  entire  roller  arranged  with  various 
convolutions,  and  in  different  manners,  and  receiving  distinctive  names 
according  to  these  differences.  Compound  bandages  consist  of  two 
or  more  pieces  of  a simple  bandage,  either  separate  or  sewed  together 
in  diverse  manners.  Mechanical  bandages  are  more  complex,  and 
are  generally  formed  of  wood,  metallic  plates,  levers,  &c. ; they  are 
also  designated  as  machines,  apparatus,  or  mechanisms,  and  are  prin- 
cipally employed  in  the  treatment  of  fractures,  dislocations,  and  dis- 
tortions. 

SECTION  I. 

GENERAL  RULES  FOR  THE  PREPARATION  AND  APPLICATION  OF  BANDAGES. 

There  are  certain  general  rules  which  control  the  preparation  and 
application  of  all  bandages,  and  these  will  therefore  require  a general 
notice. 

In  the  first  place,  all  the  pieces  of  a bandage  to  be  applied  should 
be  brought  together,  and  be  at  hand  for  immediate  use,  so  that  the 
dressing  may  not  be  delayed,  after  it  is  a third  or  half  finished,  for 
the  want  of  some  necessary  article  which  has  been  overlooked  or  mis- 
laid. The  necessities  of  each  case  ought  to  be  carefully  investigated 
before  the  bandaging  commences,  otherwise  it  may  be  found  that  it  will 
not  answer  all  the  indications  presented,  and  thus  not  only  will  time 
be  lost,  but  much  unnecessary  pain  be  inflicted  upon  the  patient.  Yet 
it  does  happen,  in  some  bases  of  fracture,  that  the  first  apparatus  will 
have  to  be  changed  or  much  modified  before  the  patient  feels  free 
from  pain ; and  it  should  never  be  forgotten  that  a bandage,  caus- 
ing continuous  pain  or  uneasiness,  inflicts  more  injury  than  can  be 
counterbalanced  by  any  good  it  may  confer.  Under  these  circum- 
stances the  patient  would  do  better  were  he  abandoned  to  his  own 
ingenuity  and  the  dictates  of  his  own  sensations. 

All  crowding  around  an  injured  person  should  be  avoided,  and  only 
such  assistants  as  the  surgeon  may  deem  necessary  to  aid  him  in  the 


132  SECOND  PIECES  OF  DRESSING,  OR  BANDAGES. 

accomplishment  of  his  object  should  participate  in  the  dressing.  Their 
duties  will  be  to  supply  promptly,  as  called  for,  the  various  articles 
that  are  wanted ; to  support  the  patient’s  limbs  after  he  has  been 
placed  in  an  easy  and  convenient  posture,  and  to  raise  him  from  the 
bed,  or  to  shift  his  position  as  the  surgeon  may  desire,  and  to  maintain 
splints  or  other  apparatus  in  their  proper  situation  until  properly 
secured.  Each  person  assisting  should  have  his  duties  assigned  him 
before  the  operation  begins,  and  under  no  circumstances  should  he 
depart  from  them,  unless  ordered  to  do  so  by  the  surgeon. 

The  bandage,  in  order  to  be  effective,  must  be  applied  with  regu- 
larity, that  the  pressure  may  be  uniform  everywhere ; and  a no  less 
important  precept  is,  to  have  such  an  amount  of  that  pressure  as  the 
case  demands,  otherwise  if  the  bandage  is  too  loose,  it  will  slip,  and 
the  object,  therefore,  will  not  be  obtained ; or,  on  the  other  hand,  if 
too  tight,  the  most  deplorable  consequences  may  ensue,  as  mortifica- 
tion of  the  parts  compressed.  The  greatest  attention  should  be  paid 
to  the  bandaging  of  recent  injuries  before  inflammatory  swelling  has 
occurred,  and  of  fractures  where  we  employ  the  immovable  apparatus. 

That  the  blood  may  not  be  arrested  in  the  lower  parts  of  the  limbs, 
and  give  rise  to  congestion,  oedema,  or  even  gangrene,  the  bandage 
ought  to  be  applied  first  to  their  distal  extremities,  and  made  to  ascend 
gradually  towards  the  trunk. 

As  to  the  material  of  which  bandages  should  be  fabricated,  linen 
cloth  is  far  preferable  to  any  other ; but  from  its  high  price,  and  the 
near  approach  to  it  in  all  useful  qualities  of  cotton  cloth,  the  latter  is 
now  most  generally  used. 

Velpegu  remarks  of  woollen  cloth  “that  it  would  often  be  preferred 
to  linen  for  bandages  if  it  were  less  dear.  Though  we  might  for  this 
purpose  make  use  of  any  kind  of  woollen  cloth,  or  stuff,  we  generally 
prefer  flannel,  and  that  almost  exclusively,  for  woollen  bandages. 
Pliable,  porous,  and  resistant  at  the  same  time,  flannel  bandages  have 
the  advantage  of  adapting  themselves  exactly  to  the  parts,  and  with 
very  little  tendency  to  become  displaced,  or  to  plait  or  roll  up  upon 
themselves ; they  also  increase  the  temperature  of  the  part,  and  readily 
absorb  excreted  fluids ; they  are  very  extensively  used  in  England. 
There  is,  however,  the  objection,  that  they  keep  up  a certain  degree 
of  irritation  upon  the  skin,  uselessly  heat  the  parts,  and  soon  become 
badly  soiled ; neither  do  they  answer  as  well  for  the  establishment  of 
reverses  as  linen  bandages,  and  are,  besides,  too  distensible,  and  of  a 
kind  that  cannot  be  readily  had  on  all  occasions.” 

Caoutchouc  and  gum-elastic  bandages  have  also  been  used,  and 
praised  for  their  elasticity  and  the  equability  of  their  pressure ; but 
these  desirable  qualities  are  more  than  counterbalanced  by  their 
impermeability  to  the  cutaneous  transpiration,  and  the  difficulty  of 
regulating  the  degree  of  pressure,  as  well  as  their  expense  and  inac- 
cessibility under  ordinary  circumstances ; and  for  these  reasons  they 
have  not  come  into  general  use. 

Cambric  and  calico  have  also  had  their  admirers,  but  they  are 
objectionable  for  bandages,  when  new,  because  of  the  glazing,  which 
readily  permits  the  turns  of  the  roller  to  slip ; and  when  the  sizing  is 


PREPARATION  AND  APPLICATION  OF  BANDAGES.  133 


•washed  out,  the  material  becomes  thin  and  yielding,  and  rolls  up  in 
cords  with  extreme  facility. 

As  the  roller-bandage  is  an  important  element  in  very  many  sur- 
gical dressings  it  demands  a special  notice.  The  cotton  cloth  of  which 
it  is  made  should  be  of  medium  thickness,  bleached,  soft,  and  new ; 
washing  destroys  to  some  extent  its  elasticity.  It  is  torn  into  strips, 
from  one  to  three  inches  wide,  and  from  one  to  ten  yards  long, 
in  the  direction  of  the  warp  of  the  stuff.  It  is  always  desirable  to 
have  each  roller  in  one  piece,  but  in  case  of  necessity  a number  may 
be  tacked  together  in  such  a manner  that  their  lines  of  junction  may 
not  produce  wheals  or  excoriations.  This  may  be  avoided  by  over- 
lapping the  ends  of  two  pieces  for  an  inch,  and  fastening  them  together 
by  what  the  sempstress  calls  the  cat-stitch,  which  will  place  the  threads 
upon  the  outer  surface  of  the  bandage,  or  they  may  be  sewed  together 
by  a running  stitch,  and  each  end  afterwards  doubled  back  upon  itself 
and  secured  by  the  cat-stitcli ; in  this  way  both  the  stitches  and  the 
free  ends  will  be  upon  the  outside.  The  selvage  should  be  removed 
from  the  edges  of  the  strips ; as  it  yields  less  than  the  balance  of  the 
cloth,  the  skin  may  be  injured  by  its  pressure.  To  prevent  the 
threads  from  ravelling,  it  has  been  suggested  to  whip-stitch  the  edges 
of  the  strips,  but  it  is  far  better  to  avoid  this,  as  all  the  loose  threads 
may  be  effectually  torn  away  from  the  ends  of  the  roller  with  the 
fingers. 

In  Germany,  long,  loose,  light,  and  elastic  strips  are  woven  for  sur- 
gical use,  with  a single  horse-hair  running  along  each  edge  under  little 
loops,  which  is  to  be  removed  when  the  rollers  are  used ; by  means  of 
the  little  loops  the  edges  of  the  band  yield  equally  with  the  balance 
of  the  material. 

Strips  are  rolled  up  for  the  purpose  of  enabling  the  surgeon  to  apply 
them  with  rapidity  and  neatness.  The  rollers  should  be  moderately 
firm  and  of  a convenient  size,  so  that  the  strip  shall  never  be  more 
than  eight  or  ten  yards  long.  A large  roller  is  apt  to  slip  from  the 
hand  and  to  interfere  with  the  neat  adjustment  of  the  bandage. 
One  is  more  likely  to  apply  a roller  too  tight  when  it  is  hard  than 
when  it  is  in  the  contrary  condition. 

In  ordinary  cases  the  surgeon  prepares  the  roller  with  his  hands ; 
while  in  hospitals,  where  large  quantities  of  bandages  are  consumed, 
a little  instrument  called  the  bandage-roller  is  commonly  employed. 

To  put  up  a roller  with  the  fingers,  select  a strip  of  the  proper 
length  and  width  and  double  one  end  of  it  upon  itself  for  eight  or  ten 
inches;  repeat  the  operation  with  the  doubled  portion  a number  of 
times,  until  a small  cylinder  is  formed,  which  should  then  be  taken  in 
the  thumb  and  first  two  fingers  of  each  hand  and  rolled  upon  itself 
until  it  assumes  sufficient  thickness  to  bear  some  pressure,  when  the 
cylinder  must  be  held  between  the  thumb  and  the  second  and  third 
fingers  of  the  right  hand,  that  side  of  it  facing  the  surgeon  to  which 
the  free  portion  is  tangent,  and  the  unwound  part  between  the  radial 
border  of  the  left  hand  and  thumb;  the  last  three  fingers  of  this  hand 
are  extended  under  the  cylinder,  and  by  their  pressure  and  the  alter- 
nate supination  and  pronation  of  the  left  hand  it  is  made  to  revolve 


134  SECOND  PIECES  OF  DRESSING,  OR  BANDAGES. 

rapidly  (Fig.  80).  Should  the  hand  supporting  and  tightening  the 
wound  portion  of  the  bandage  become  fatigued,  the  other  hand  must 


Fig.  80. 


be  made  to  relieve  it.  At  any  time  during  the  rolling,  the  turns  upon 
the  cylinder  may  be  drawn  firmer  by  simply  holding  it  by  its  ends 
between  the  forefinger  and  thumb  of  the  right  hand,  while  strong 
traction  is  made  upon  the  free  portion  with  the  left. 

From  the  fact  that  the  free  end  of  the  roller  is  first  applied,  it  is 
called  its  “ initial  extremity,”  and  the  other  end  of  the  strip,  now  in 
its  centre,  the  “ terminal  extremity,”  and  the  roller  is  said  to  be  single- 
headed. When  the  strip  is  rolled  from  both  of  its  extremities  the 


Fig.  81. 


double-headed  roller  is  formed,  and  that  portion  intervening  between 
the  two  heads  is  called  its  “ body,”  while  both  ends  are  then  '‘terminal” 


PREPARATION  AND  APPLICATION  OF  BANDAGES.  135 

and  at  the  centres  of  the  cylinders.  This  roller  is  made  in  the  same 
manner  as  described  above. 

The  machine  (Fig.  81)  for  rolling  bandages  is  very  simple,  consist- 
ing of  a metallic  spindle  supported  upon  two  uprights  or  columns, 
and  revolved  by  a crank ; opposite  the  spindle  there  are  two  horizontal 
bars,  or  a board  with  two  parallel  slits  cut  in  it,  for  the  purpose  of 
supporting  and  regulating  the  tension  upon  the  strips.  To  render 
the  machine  stationary  while  it  is  being  used,  it  is  fastened  to  a table 
or  bench  with  a large  wooden  screw  and  clamp. 

The  manner  of  applying  a single-headed  roller  is  to  take  it  by  its 
extremities  between  the  thumb  and  the  second  and  third  fingers,  or 
to  hold  it  in  the  palm  of  the 
hand  between  the  thumb  and 
the  four  fingers;  in  either  case, 
that  part  of  the  cylinder  to 
which  the  free  portion  is  tan- 
gent ought  to  look  from  the 
surgeon.  Then  unwind  the 
initial  extremity  a little  and 
lay  its  external  surface  upon 
that  part  of  the  circumference 
•*  of  the  limb  opposite  to  the 
injury,  and  hold  it  there  with 
the  point  of  the  finger  or 
thumb  of  the  left  hand,  while 
two  or  three  circular  turns  are 
being  made  to  secure  it  from 
slipping.  Now  the  turns  may 
be  successively  applied,  each 
covering  in  a half  or  two- 
thirds  of  the  width  of  its  pre- 
decessor, until  the  entire  roller 
is  exhausted.  But  owing  to 
the  conical  shape  of  the  limbs, 
a bandage  applied  circularly 
in  this  manner  will  press  upon 
the  surface  by  its  superior 
border  only,  leaving  the  lower  one  standing  off  from  the  part,  and 
forming  pockets  or  puckers ; to  avoid  these  an  oblique  direction  must 
be  given  to  the  turns,  forming  what  are  called  dobires,  each  of  which 
overlaps  two-thirds  of  the  one  that  precedes  it ; if  they  simply  touch 
by  their  edges,  the  spiral  is  said  to  be  rampant.  The  turns  of  a 
roller  applied  in  this  manner  are  apt  to  slip,  and  cannot  be  laid  down 
smoothly  enough  upon  a very  conical  part  to  make  uniform  pressure 
upon  it,  and  we  are,  therefore,  compelled,  in  order  to  avoid  this  in- 
convenience, to  change  its  direction  at  every  turn ; in  other  words, 
to  make  what  are  termed  “reverses.”  This  is  done  in  the  following 
manner : When  the  roller  has  passed  the  point  upon  which  a reverse  is 
designed  to  be  placed,  a distance  of  five  or  six  inches,  the  turn  is  held 
against  the  limb  by  the  point  of  the  index  finger  or  thumb  of  the  left 
hand,  while,  with  the  right,  the  roller  is  drawn  backwards  and  folded 


Fig.  82. 


136  SECOND  PIECES  OF  DRESSING,  OR  BANDAGES. 

upon  itself  by  pronating  the  hand,  as  seen  in  Fig.  82,  so  that  the  supe- 
rior border  of  the  turn  becomes  the  inferior,  and  the  external  face  the 
internal ; the  reverse  must  then  be  tightened  by  gentle  traction  upon 
the  roller. 

To  give  a neat  appearance  to  the  bandage,  these  reverses  may  be 
arranged  in  the  same  vertical  line  upon  the  limb;  and  to  insure  the 
greatest  uniformity  of  pressure  the  oblique  edges  'which  they  form 
by  folding  must  not  exceed  the  width  of  the  roller,  else  they  are  liable 
to  constrict  the  limb  like  cords. 

The  direction  of  the  turns,  as  they  are  generally  applied  by  a right- 
handed  person,  is  from  left  to  right,  that  is,  from  without  inwards  for 
the  right  leg.  and  the  reverse  for  the  left  leg ; but  this  is  entirely  a 
matter  of  choice,  for  the  best  rule  is,  that  that  method  of  applying  a 
bandage  should  always  be  selected  which  will  insure  the  neatest  and 
most  efficient  result. 

In  employing  the  double  headed  roller,  there  is  a little  more  diffi- 
culty, perhaps,  encountered  than  in  the  previous  case.  Gerdy  directs 
it  to  be  accomplished  in  the  following  manner : “ Seize  the  two  cylin- 
ders in  both  hands,  apply  the  external  surface  of  the  intermediate 
portion  or  body  upon  a point  of  the  circumference  of  the  part  which  the 
bandage  is  to  cover ; afterwards  unwind  at  the  same  time  and  to  an 
equal  degree  the  two  cylinders  around  the  part  until  you  have  carried 
them  to  a point  opposite  that  at  which  you  commenced  the  bandage ; 
in  this  place  deviate  one  of  the  cylinders  obliquely  upwards  or  down- 
wards, continue  on  the  contrary  to  carry  the  other  with  its  band  in  a 
horizontal  line  until  the  latter  meets  the  unwound  portion  of  the  first, 
which  it  covers  and  crosses,  forming  an  acute  angle ; then  turn  and 
reverse  obliquely  the  first  cylinder  and  its  oblique  unwound  portion 
upon  the  circular  part  of  the  second  cylinder,  which  covers  in  and 
crosses  it;  afterwards  making  the  two  cylinders  pursue  their  original 
direction,  bring  them  a little  above  the  point  of  departure  and  com- 
mence again  in  front  the  same  manoeuvre  that  has  been  done  behind ; 
proceed  in  this  manner  until  the  roller  is  exhausted,  and  fix  the  last 
convolutions,  as  well  as  one  of  the  terminal  ends,  by  horizontal  cir- 
cular turns  made  with  the  more  voluminous  cylinder.” 

There  are  several  modes  of  fixing  the  terminal  ends  of  roller 
bandages ; that  most  commonly  employed  is  to  secure  them  with  pins 
which  should  be  always  introduced  with  their  heads  looking  towards 
the  free  extremity  of  the  roller ; for  if  the  point  projects  in  that  direc- 
tion, the  traction  of  the  bandage  will  soon  cause  it  to  stick  out  and 
catch  in  everything  coming  in  contact  with  the  part,  or  it  may  wound 
the  hands  of  the  patient  or  surgeon.  If  the  end  of  the  strip  is  narrow, 
its  corners  may  be  turned  under  so  as  to  form  an  acute  angle  into 
which  one  pin  may  be  introduced  to  confine  it;  if  it  is  broader,  a pin 
in  each  corner  and  one  in  the  centre  will  be  necessary.  Sometimes  a 
couple  of  pieces  of  tape  are  sewed  to  the  end  of  the  roller,  which  is 
then  fastened  by  a double  bow-knot.  Bandages  of  the  fingers  are 
often  secured  by  simply  winding  a thread  around  them  several  times 
and  tying  it.  By  splitting  the  free  end  of  the  roller  to  the  extent  of 
five  or  six  inches,  two  tails  are  formed,  which  may  be  bound  arouud 


mayor’s  system  of  bandaging. 


137 


the  finger  and  knotted.  Still  another  way  of  securing  a bandage  is  to 
permit  a few  inches  of  its  initial  extremity  to  remain  free,  and,  when 
the  roller  is  exhausted,  tie  the  terminal  and  initial  ends  in  a bow-knot. 

SECTION  II. 

SPECIAL  SYSTEMS  OF  BANDAGING. 

1.  Mayor’s  System  of  Bandaging. — Although  simple  square 
pieces  of  cloth  variously  folded  were  often  employed  by  the  ancients 
in  bandaging,  yet  it  remained  for  M.  Mathias  Mayor,  of  Lausanne,  to 
systematize  and  base  upon  uniform  and  rational  principles  their 
employment.  He  has  also  added  others  of  his  own  invention,  and  has 
designated  them  all  by  names  grounded  upon  a scientific  anatomical 
nomenclature.  For  instance,  he  commonly  employs  two  or  more  ana- 
tomical terms  joined  together  to  designate  each  bandage ; the  first 
term  pointing  out  the  part  to  which  its  body  or  base  should  be 
applied,  and  the  second  that  over  which  its  extremities  should  be 
tied.  Thus,  the  fronto-occipital  triangle  indicates  that  the  base  of  the 
triangle  is  over  the  forehead,  and  that  its  ends  are  fastened  upon  the 
occiput ; so  in  the  fronto-cervico-labial  cravat,  the  body  of  the  band- 
age is  upon  the  forehead ; it  is  crossed  upon  the  neck,  and  its  ends  are 
finally  fastened  in  front  of  the  lip ; and  in  like  manner  the  same  plan 
is  carried  out  through  the  whole  series. 

This  system  is  ingenious  and  really  useful  under  certain  circum- 
stances; but  it  certainly  will  never  even  partially  supplant  the  use 
of  the  ordinary  bandages,  much  less  become  generally  adopted,  as 
was  intended  by  M.  Mayor.  Although  the  highest  meed  of  praise 
has  been  accorded  to  the  system  by  most  surgeons,  yet  they  have 
never  failed  to  recognize  several  essential  defects  in  it  which  will 
always  restrict  its  employment  within  very  narrow  limits.  For 
instance,  these  bandages  cannot  be  expected  to,  and  they  do  not,  act 
efficiently  in  varicose  veins,  oedema,  and  some  cases  of  hemorrhage,  etc., 
where  a uniform  and  continuous  pressure  is  necessary ; in  fractures 
they  are  all  but  useless  as  permanent  dressings,  on  account  of  their 
want  of  solidity  and  power  to  maintain  the  reduction  of  a broken 
bone.  No  one  will  deny  this  statement  should  he  attempt  the  treat- 
ment of  a case  of  oblique  fracture  of  both  bones  of  the  leg  with 
cravats  and  the  hyponarthecic  board.  These  are  objections  of  a vital 
character ; but  there  are  others  of  a more  trivial  nature,  among  which 
may  be  mentioned  the  pressure  of  the  knots  by  which  the  bandages 
are  fastened,  as  well  as  the  creases  and  folds  which  are  necessarily 
formed  by  them  upon  parts  already  sensitive  and  tender. 

On  the  other  hand,  the  advantages  of  the  system  are,  first,  should 
the  surgeon  be  so  situated  that  more  efficient  bandages  and  apparatus 
cannot  be  obtained,  as  often  happens  during  the  exigencies  of  war 
both  to  army  and  naval  surgeons,  he  will  find  in  the  handkerchief  and 
its  modifications  the  best  possible  substitute  for  them ; secondly,  the 
preparation  and  application  of  these  bandages  are  so  simple  that,  with 
very  little  instruction,  any  intelligent  person  can  manage  them  suffi- 
ciently well  to  put  on  a provisional  dressing,  the  timely  use  of  which, 
in  battle  or  after  accidents,  may  determine  the  future  fate  of  a pa- 


138  SECOND  PIECES  OF  DRESSING,  OR  BANDAGES. 

tient ; thirdly,  the  materials  of  the  bandages — a common  handkerchief 
or  square  piece  of  muslin,  or  any  kind  of  cloth — are  to  be  found 
everywhere,  and  always  ready  prepared  for  immediate  use. 

These  are  the  prominent  disadvantages  and  advantages  of  M.  Mayor's 
handkerchief  system ; and  although  he  did  not  design  it  to  supplant 
the  place  of  the  ordinary  method  of  bandaging  at  once,  yet  he  believed 
that  rigorously  it  might  do  so  under  all  circumstances.  The  experi- 
ence of  other  surgeons  is  so  different,  however,  from  that  of  M.  Mayor, 
that  they  only  employ  his  bandages  to  retain  other  dressings  in  place, 
to  act  as  simple  supports  to  parts,  to  serve  as  provisional  dressings, 
and,  lastly,  to  be  used  under  circumstances  of  necessity  where  the  roller 
and  other  bandages  are  unattainable. 

M.  Mayor  prepares  all  of  his  bandages  from  one  primitive  form — 
a square  piece  of  muslin  (Fig.  83) — which  is  itself  rarely  used. 


Fig.  84. 


1.  The  Oblong  (Fig.  84)  is  formed  from  the  square  by  twice  folding 
the  latter  in  the  direction  of  the  transverse  lines. 

2.  The  Triangle  (Fig.  85)  results  from  the  folding  of  the  square  in 
the  direction  of  the  diagonal  line.  The  middle  third  of  this  line  Mayor 
calls  the  base  of  the  triangle,  and  the  two  lateral  thirds  the  “ extremi- 
ties,” or  chiefs,  and  the  angle  opposite  the  base  the  “apex,”  or  “summit.” 

3.  The  Cravat  (Fig.  86)  is  prepared  from  the  triangle  by  bringing 
the  apex  to  its  base,  and  folding  it  a number  of  times  upon  itself,  to 
obtain  the  width  and  thickness  we  desire  it  to  have. 


Fig.  86. 


The  cravat. 


4.  The  Cord  (Fig.  87)  is  nothing  but  the  cravat  twisted  upon  itself. 
We  shall  consider  the  special  application  of  these  bandages  in 
Chapter  VIII. 


THE  INDICATIONS  ANSWERED  BY  BANDAGES.  139 


Fig.  87. 


The  cord. 


2.  M.  Rigal’s  System  of  Bandaging. — M.  Rigal,  animated  by- 
motives  similar  to  those  which  induced  M.  Mayor  to  adopt  his  system 
of  handkerchief  bandages,  has  also  proposed  one  of  his  own,  differing 
from  Mayor’s  in  two  principal  respects.  1st.  Observing  that  the  cra- 
vats and  triangles  of  that  author  formed  creases  and  puckers  when 
applied  to  the  body,  which  caused  them  to  be  easily  displaced,  he 
endeavored  to  remedy  this  defect  by  cutting  the  pieces  of  muslin  into 
different  shapes,  so  that  they  might  rest  smoothly  upon  the  surface. 
2d.  Observing  also  that,  their  ends  being  firmly  knotted  together,  the 
bandages  were  thrown  from  their  proper  position  by  the  movements  of 
the  patient,  he,  to  obviate  this,  introduced  the  use  of  gum-elastic  cords 
to  fasten  them.  “Which  combination,”  says  M.  Rigal,  “ has  the  advan- 
tage of  fastening  the  pieces  of  muslin  together  in  such  a manner  that 
they  cannot  be  deranged.  In  spite  of  the  most  varied  movements  of  a 
patient,  the  degree  of  compression  determined  by  the  surgeon  remains 
sensibly  uniform;  the  play  of  the  lower  jaw,  that  of  the  osseous  walls 
of  the  thorax,  the  different  inclinations  of  the  trunk,  the  alternate 
flexion  and  extension  of  the  members,  all  these  do  not  change  at  all 
the  first  arrangement  established.” 

The  same  objections  which  have  already  been  made  to  Mayor’s 
system  may  be  urged  with  still  stronger  reason  against  Rigal’s ; at  the 
same  time,  it  wants  one  of  the  peculiar  advantages  of  the  former,  viz., 
that  the  materials  are  always  at  hand.  Elastic  threads  of  different 
sizes  and  lengths  can,  probably,  be  found  only  in  cities,  and  any  mili- 
tary or  rural  surgeon  so  well  off  in  resources  as  to  possess  a supply 
of  these  will  be  most  likely  to  have  also  at  command  other  means 
superior  to  the  bandages  of  Rigal.  Yet  the  ingenuity  displayed  in 
their  construction,  and  their  fitness  in  certain  cases,  demand  for  them 
a cursory  description.  We  have,  therefore,  considered  their  special 
application  in  Chapter  VIII. 


SECTION  III. 

THE  INDICATIONS  ANSWERED  BY  BANDAGES. 

As  we  propose  to  study  the  bandages  in  anatomical  order,  it  will  be 
necessary  to  devote  a few  pages  to  the  consideration  of  the  indications 
which  they  are  capable  of  fulfilling. 

Notwithstanding  the  multiplicity  of  surgical  bandages  and  apparatus, 
they  may  all  be  reduced  to  a few  classes  expressive  of  their  mode  of 
action  and  the  common  principles  upon  which  they  are  founded.  Of 
course  such  a classification  cannot  be  rigidly  adhered  to,  inasmuch 
as  the  same  bandage  may  at  one  time  belong  to  one  class,  and  at 
another  to  an  entirely  different  one ; or,  again,  its  mode  of  action  may 
assimilate  it  to  two,  and  even  three,  different  classes  at  the  same  time: 
thus,  a bandage  may  be  at  once  compressive  and  expelling,  or  pro- 


140  SECOND  PIECES  OF  DRESSING,  OR  BANDAGES. 

tective,  compressive,  and  expelling.  Indeed,  there  are  but  few  band- 
ages whose  action  is  single;  we  often  lay  a piece  of  cerated  muslin  or 
other  cloth  upon  an  ulcerated  leg,  and  secure  it  with  a few  turns  of 
the  roller,  to  protect  the  sore  from  external  irritants  while  the  healing 
process  is  being  perfected,  and  we  also  bandage  with  the  roller  an 
oedematous  leg,  with  the  object  of  making  compression  only;  but 
when  both  of  these  conditions  obtain  in  the  same  leg,  the  bandage 
necessarily  becomes  both  protective  and  compressive. 

Yet,  for  perspicuity,  we  shall  speak  of  the  actions  of  these  classes  as 
if  they  were  entirely  distinct,  and  will  refer  occasionally  to  those  special 
cases  of  disease  in  which  their  action  is  markedly  seen ; and,  to  further 
develop  the  subject,  we  shall  not  hesitate  to  allude  to  the  action  of 
certain  surgical  instruments  based  upon  the  same  principle. 

One  of  the  simplest  indications  answered  by  a bandage  is  to  protect 
parts  from  the  contact  of  irritating  agents,  as  when  we  put  a shield 
over  the  eye,  to  ward  off  the  glare  of  the  light  in  various  diseases  of 
that  organ  attended  with  an  increased  sensitiveness  of  the  retina;  or 
when  we  cover  delicate  and  granulating  surfaces  with  a fine  compress, 
to  defend  them  from  the  action  of  dust,  or  the  clothes  of  the  person, 
or  his  bed.  Here  the  object  is  simply  to  interpose  a defence  between 
the  external  agents  and  the  surface  of  the  body;  but  it  happens  most 
frequently  that,  besides  performing  these  functions,  the  bandage  serves 
the  further  purpose  of  a vehicle  of  certain  medicaments,  as  simple 
cerate,  the  narcotic  ointments,  basilicon  ointment,  or  other  substances, 
which  are  spread  upon  its  under  surface  for  the  purpose  of  diminishing 
morbid  irritability,  altering  diseased  action,  stimulating  indolent  granu- 
lations, or  of  correcting  the  fetor  of  suppurating  discharges. 

An  equally  simple  action  is  that  of  the  retaining  bandages,  which 
are  intended  to  hold  dressings  upon  parts,  or  to  prevent  organs  from 
again  escaping  from  their  natural  cavities  after  having  been  once 
replaced.  It  is  upon  this  principle  that  the  different  kinds  of  trusses, 
pessaries,  &c.,  have  been  constructed.  In  fractures,  also,  the  apparatus 
used  in  their  treatment  rather  retains  broken  bones  in  their  normal 
position  by  offering  a solid  resistance  than  by  any  actual  force  of  com- 
pression. It  could  scarcely  happen  that  any  amount  of  compression 
brought  to  bear  upon  a fractured  bone,  by  bandages  or  apparatus, 
would  establish  the  normal  relations  of  its  fragments,  if  displaced, 
before  the  reduction  has  been  accomplished ; and  in  this  case  no  such 
force  will  be  required;  the  retaining  power  alone  of  the  apparatus  will 
be  all  that  is  needed  to  maintain  the  reduction. 

In  the  hernial  protrusions  of  adults,  the  elastic  resistance  of  the 
truss-spring  prevents  the  bowels  from  escaping  externally,  and  the 
truss  has  generally  to  be  worn  the  balance  of  the  patient's  life;  in 
children,  however,  a well-fitting  truss,  with  a pad  bearing  upon  the 
whole  length  of  the  inguinal  canal,  will  not  only  hinder  the  extrusion 
of  the  abdominal  viscera,  but  often  effect  a radical  cure  by  obliterating 
the  neck  of  the  hernial  sac  by  the  compressive  force  of  the  pad. 

In  prolapses  of  the  uterus,  vagina,  and  anus,  retentive  bandages 
have  been  employed  with  success.  Those  intended  for  the  two  former 
organs  are  called  pessaries.  Of  these  there  are  two  forms : the  first 


THE  INDICATIONS  ANSWERED  BY  BANDAGES.  141 


consisting  of  a metallic  instrument  to  be  introduced  into  the  vagina 
and  supported  in  situ  by  an  external  bandage,  as  the  bilboquet  pessary ; 
the  second  kind  have  no  external  support,  but  take  their  point  cVappui 
upon  the  vaginal  walls:  the  latter  are  now  almost  exclusively  used  in 
this  country.  Pessaries  introduced  into  the  vagina  not  only  impede  the 
descent  of  the  uterus  by  the  resistance  which  they  offer  to  that  organ 
in  consequence  of  being  supported  themselves  by  the  walls  of  the 
vagina,  but  at  the  same  time  they  distend  the  upper  part  of  this  canal, 
which  contributes  largely  to  their  retentive  power. 

In  prolapse  of  the  rectum,  the  retentive  bandage  consists  of  a perineal 
strap  which  bears  upon  its  upper  surface  a pelote  or  lcnot-like  projection 
intended  to  press  against  the  anus;  this  strap  is  held  in  place  by  being 
buckled  in  front  and  behind  to  another  strap  passing  around  the  loins. 
A better  form,  however,  of  this  bandage  is  that  where  the  pelote  is  sup- 
ported at  the  extremity  of  a steel  spring  which  takes  its  point  dCappui 
from  a pelvic  strap.  The  principle  of  retention  is  involved  in  a great 
number  of  other  bandages,  but  the  above  examples  sufficiently  illus- 
trate it. 

Suspensory  bandages  are  used  to  support  swollen  and  pendulous 
organs,  to  prevent  their  weight  causing  dragging  pains,  and  to  facili- 
tate the  circulation  of  blood  in  them.  The  female  breast  sometimes 
becomes  greatly  enlarged,  either  from  simple  inflammation  or  can- 
cerous disease,  and  demands  that  it  be  effectually  supported.  We 
accomplish  this  by  using  one  of  the  crossed  bandages  or  slings  of  the 
breast,  or  by  adhesive  plaster,  as  seen  in  Fig.  88.  The  strips  should 


Fig.  88. 


be  sufficiently  long  to  pass  around  the  breast  and  shoulder,  and  every 
part  of  its  surface  except  the  nipple  must  be  covered  in. 

The  testicles  suffer  in  a similar  manner,  and  are  maintained  in  an 


142  SECOND  PIECES  OF  DRESSING,  OR  BANDAGES. 


elevated  position  by  tbe  well-known  woven  suspensory  bandages  of 
the  shops. 

Large  and  irreducible  hernial  protrusions  also  require  some  sort 

of  a supporting  bandage,  to 
prevent  those  painful  dragging 
sensations  in  the  abdomen 
which  their  weight  produces. 
These  are  sometimes  so  large 
that  they  contain  most  of  the 
abdominal  viscera;  the  stomach 
even  may  become  partially  ex- 
truded, and  in  these  cases  the 
patients  are  destined  for  the  rest 
of  their  natural  lives  to  carry 
these  enormous  tumors  in  a 
sling.  In  women  the  abdomen 
sometimes  becomes  pendulous, 
and  requires  to  be  efficiently 
supported,  and  for  this  purpose 
the  bandage  seen  in  Fig.  89  is 
well  adapted.  It  resembles  the 
corset  usually  worn  by  ladies, 
and  is  rendered  firm  and  elastic 
by  vertical  strips  of  whalebone 
introduced  between  the  outer 
and  inner  surfaces ; to  prevent 
it  slipping  up,  which  it  ought 
not  to  do,  however,  if  well  made,  two  thigh  straps  are  attached  to  the 
bandage. 

Professor  N.  R.  Smith,  of  Baltimore,  has  generalized  the  principle 
of  suspension  in  the  treatment  of  fractures,  and  there  is  no  doubt 
but  that  his  anterior  wire  splint  is  an  improvement  upon  the  ordi- 
nary suspensory  apparatus;  it  is  of  especial  value  in  those  cases  of 
fracture,  attended  with  wounds  of  the  soft  parts  at  the  seat  of  the 
injury.  I have  used  a wire  splint  to  suspend  the  arm  in  gunshot 
wounds  of  the  palm  of  the  hand  with  decided  advantage ; it  permits 
the  arm  to  be  placed  in  any  position,  either  for  the  renewal  of  the 
dressing  and  cleansing  the  parts,  or  to  facilitate  the  escape  of  pus; 
the  suspending  cord  may  be  attached  above  to  the  ceiling  or  to  a hoop 
placed  over  the  injured  limb. 

Expelling  bandages  are  such  as  cause  any  accumulated  secretions  to 
flow  out  from  the  cavities  in  which  they  may  be  contained  by  exercis- 
ing compression,  as  is  seen  in  cases  of  large  phlegmonous  and  diffused 
abscesses  where  an  expelling  bandage  is  applied  to  force  the  secreted 
fluids  externally  and  to  bring  the  opposite  walls  of  the  cavity  in  con- 
tact. With  the  same  view  the  proper  bandaging  of  a suppurating 
stump  will  have  an  important  influence  upon  the  result  of  the  opera- 
tion, and  especially  when  this  has  been  effected  by  the  flap  method ; 
for,  under  these  circumstances,  pockets  and  purulent  collections  are 
more  apt  to  form  than  when  the  circular  operation  is  performed.  I 


Fig.  89. 


Velpeau’s  bandage  for  supporting  a pendulous 
abdomen. 


THE  INDICATIONS  ANSWERED  BY  BANDAGES.  143 


think  I have  seen  death  take  place  in  several  instances  after  amputa- 
tion in  the  hospitals,  during  the  late  war,  from  pyemia,  the  result  of 
allowing  the  end  of  the  bone  to  be  bathed  in  acrid  pus.  In  various 
cases  of  fistulas  and  sinuses  expelling  bandages  are  also  used. 

Uniting  bandages  are  employed  to  hold  the  margins  of  wounds 
together  while  nature  effects  their  union.  Generally,  the  surgeon  de- 
pends upon  adhesive  plaster,  position,  pressure,  and  the  suture,  as  the 
most  efficient  means  to  accomplish  this  object.  Yet  these  may  be 
materially  assisted  by  the  uniting  bandages,  such  as  those  for  horizon- 
tal and  vertical  wounds.  In  some  wounds  uniting  bandages  are  in- 
dispensably necessary,  as  in  transverse  incisions  upon  the  throat, 
which  require  the  head  to  be  flexed  upon  the  chest.  To  support  the 
suture  after  the  operation  for  harelip,  Mr.  Dewar,  of  Scotland,  invented 
a contrivance  consisting  of  a circular  elastic  steel  spring,  reaching 
from  the  back  and  base  of  the  skull  forwards  to  each  side  of  the 
fissure  in  the  lip,  and  terminating  there  in  two  little  pads ; two  verti- 
cal straps  hold  the  spring  in  its  place.  The  pads  press  the  tissues 
forwards,  and  thus  relieve  the  strain  upon  the  twisted  suture  holding 
the  edges  of  the  fissure  together,  as  seen  in  Fig.  90. 

The  object  of  dividing  bandages  is  exactly  the  reverse  of  the  pre- 
ceding class,  and  they  are  much 
more  difficult  of  management.  In 
wounds  attended  with  considerable 
loss  of  substance,  as  those  from 
burns,  gangrene,  &c.,  dividing 
bandages  are  employed  often  with 
the  best  results  in  preventing,  or, 
at  least,  alleviating,  the  contrac- 
tion of  the  cicatrices  resulting 
from  them.  Cases  of  this  kind 
sometimes  occur  which,  if  aban- 
doned to  the  curative  effects  of 
nature  alone,  would  present  a 
frightful  amount  of  deformity  and 
loss  of  function  of  important  or- 
gans, as  we  see  in  burns  of  the 
neck,  in  which  the  contracting 
cicatrices  sometimes  draw  the 
lower  jaw  down  upon  the  chest 
in  such  a manner  that  the  teeth 
are  exposed,  and  cannot  be  brought 
in  apposition,  and  the  saliva 
dribbles  away  from  the  mouth 
involuntarily,  thus  destroying  at  once  two  important  steps  in  diges- 
tion— mastication  and  insalivation — and  necessarily  impairing  in  a 
serious  manner  the  nutrition  of  the  patient.  In  the  upper  extremity 
cicatrices  may  bind  it  to  the  side  of  the  chest,  or  destroy  the  functions 
of  the  fingers.  From  this  it  may  be  seen  that  it  is  of  the  greatest  im- 
portance to  attend  to  the  early  treatment  of  such  cases  with  dividing- 
bandages  ; for  although  plastic  surgery  has  done  much  to  relieve  the 


Dewar’s  apparatus  for  supporting  the  suture 
in  harelip. 


144  SECOND  PIECES  OF  DRESSING,  OR  BANDAGES. 

deformities  following  such  injuries,  yet  we  must  depend  upon  the 
former  for  satisfactory  results  during  the  cicatrizing  process,  and  en- 
deavor to  save  the  patient  from  a future  dangerous  and  often  unsatis- 
factory surgical  operation.  There  are  other  means,  besides  these  band- 
ages, used  by  the  surgeon  to  prevent  the  premature  union  of  wounds. 
For  instance,  after  the  operation  for  fistula  in  ano,  he  packs  lint  in 
the  incision  to  hinder  the  agglutination  of  its  edges  before  the  bottom  , 
of  the  wound  has  healed.  He  also  introduces  into  the  orifices  of  cer- 
tain canals,  after  being  injured,  and  into  the  punctures  made  in  ab- 
scesses, bits  of  lint,  elastic  bougies,  &c.,  to  prevent  unwished-for  closure. 

Of  all  the  indications  which  bandages  fulfil,  there  is,  perhaps,  no 
one  as  important  as  that  of  compression,  considered  either  in  the 
extent  of  its  applicability  or  in  the  magnitude  of  the  cases  in  which  it 
is  employed.  The  use  of  a large  number  of  bandages  and  surgical 
instruments  is  based  upon  this  principle.  Moderate  pressure  upon 
parts  of  the  human  body  aids  their  contractile  power  and  excites 
their  absorbents  to  an  increased  action,  so  that  under  its  influence 
large  tumors  and  certain  organized  effusions  often  disappear.  When 
it  is  increased  and  continued,  the  nutritive  functions  are  disturbed 
and  atrophy  is  the  consequence.  When,  again,  the  pressure  is  carried 
still  further  and  becomes  excessive,  the  parts  below  the  point  where 
the  compression  is  exercised  become  numb,  torpid,  and  insensible; 
their  circulation  is  arrested;  they  grow  cold,  and  finally  mortify.  In 
cedematous  conditions  of  the  extremities,  particularly  in  the  legs, 
gentle  pressure,  exercised  by  a neatly-applied  reverse  turn  bandage, 
will  cause  the  effusion  to  disappear,  and  give  tone  to  the  parts  by  cor- 
recting the  abnormal  dilatation  of  the  capillaries  and  smaller  blood- 
vessels. Of  course  it  is  necessary,  for  all  this  good  to  follow,  that  the 
effusion  should  not  depend  upon  organic  disease  of  interior  organs 
essential  to  life. 

Some  surgeons  are  in  the  habit  of  applying  a roller  bandage  to 
the  entire  length  of  a fractured  limb,  with  a view  of  preventing 
the  spasmodic  action  of  the  muscles,  ivhile  others  consider  it  either 
unnecessary  or  inefficient,  believing  that  the  splints  commonly  em- 
ployed in  such  cases  will  exercise  all  the  compression  necessary  to 
effect  this  object.  As  to  the  relative  efficacy  of  one  or  the  other  of  these 
plans  of  making  compression,  the  question  can  soon  be  decided  if  we 
but  reflect  that  a contracting  muscle  increases  in  diameter  and  dimi- 
nishes in  length,  so  that  it  is  very  apparent  that  any  force  brought 
counter  to  this  diametric  enlargement  must  diminish  the  extent  of 
muscular  contraction,  if  it  does  not  entirely  prevent  it;  and  the  roller 
bandage,  pressing  uniformly  upon  the  whole  extent  of  the  muscular 
surface,  as  it  does,  and  exactly  in  an  opposite  direction  to  the  expansive 
force  of  the  muscles,  must  be  more  efficient  in  controlling  this  than 
splints,  which  exercise  compressive  force  upon  a very  narrow  extent 
of  surface,  and  do  not,  therefore,  hinder  the  muscles  spreading  in  a 
direction  at  right  angles  with  the  planes  of  the  splints — that  is,  in  the 
direction  in  which  they  are  not  opposed. 

There  does  not  appear  to  be  any  difference  of  opinion  as  to  the 
advantages  of  applying  compressive  bandages  to  stumps  after  amputa- 
tion of  the  limbs,  for  the  reason  that,  under  such  circumstances,  one  of 


THE  INDICATIONS  ANSWERED  BY  BANDAGES.  145 

the  points  of  attachment  of  the  muscles  being  destroyed  there  is  no 
obstacle  to  their  contracting  and  thereby  drawing  up  the  flaps.  After 
watching  the  progress  of  numerous  amputations  I am  convinced  that, 
with  more  skilful  bandaging  and  shorter  flaps  than  are  commonly  seen 
in  hospitals,  not  only  can  better  stumps  be  obtained,  but,  what  is  of  more 
importance,  the  period  of  healing  can  be  abridged  and  thereby  more  lives 
be  saved.  The  chief  error  I observed  during  the  Avar,  in  amputating, 
consisted  in  cutting  the  flaps  too  long,  so  that  after  one  battle,  of  a large 
number  of  these  operations  but  one  patient  had  the  flaps  too  short  (and 
the  flap  operation  Avas  generally  adopted),  Avhile  a large  number  had 
them  too  long.  Of  the  latter  cases  there  Avas  one  in  particular,  a man 
whose  thigh  had  been  amputated,  in  which  the  bone  had  been  sawn 
through  in  the  upper  third,  and  the  incisions  made  near  the  lower 
third,  so  that  the  soft  parts  formed  two  huge  flaps,  an  anterior  and  a 
posterior,  which,  in  spite  of  the  most  skilful  attention,  kept  suppurating 
until  the  patient  died  from  sheer  exhaustion.  There  Avas  no  doubt  in 
this  case  that,  had  the  operation  been  performed  otherwise,  and  the 
stump  properly  bandaged,  the  patient  would  have  made  a happy  re- 
covery. I Avas  enabled  to  follow  up  and  take  accurate  notes  of  thirty- 
five  cases  of  amputations;  good  stumps  Avere  obtained  in  all,  and  the 
circular  operation,  with  flaps  of  the  skin  and  cellular  tissue  only,  was 
adopted  in  every  case,  care  being  always  taken  to  have  just  enough 
of  the  soft  parts  to  cover  the  end  of  the  stump,  and  no  more,  and  to 
bandage  carefully.  I saAv  one  case,  that  of  an  officer,  in  which  the 
thigh  had  been  amputated  at  three  different  points  in  consequence  of 
the  retraction  of  the  soft  parts  from  improper  bandaging. 

The  consideration  of  compression  as  a hemostatic  means  we  shall 
defer  until  we  come  to  the  subject  of  hemorrhage. 

Somewhat  connected  with  this,  however,  is  the  subject  of  aneurism, 
in  the  treatment  of  which  compression  has,  within  the  last  twenty-five 
or  thirty  years,  assumed  great  importance.  A number  of  scores  of 
years  ago,  recourse  was  often  had  to  direct  pressure  upon  aneurismal 
tumors,  but  it  was  not  until  1760  that  Vernet,  a French  surgeon, 
introduced  the  present  practice  of  making  compression  upon  the 
course  of  the  artery  above  the  tumor.  After  having  made  this 
important  step,  the  treatment  of  this  disease  was  far  from  being 
scientific  and  based  upon  exact  observation ; for  the  idea  entertained 
Avas  to  bring  such  a compressing  force  upon  the  artery  as  to  obliterate 
its  cavity  by  pressing  its  Avails  into  contact,  and  in  doing  this  great 
pain  and  suffering  were  necessarily  inflicted  upon  the  patient,  so  that 
feAv  had  either  the  nerve  to  begin,  or  the  endurance  to  sustain  such  a 
mode  of  treatment.  The  true  principle  was,  however,  at  last  dis- 
covered and  firmly  established  by  the  labors  of  several  eminent 
Dublin  surgeons  and  others,  among  whom  were  Bellingham,  Dutton, 
Carte,  and  Tafnel.  They  discovered  that  it  was  only  necessary  to 
make  such  a degree  of  compression  as  to  retard  the  current  of  blood 
through  the  aneurismal  tumor  in  order  to  bring  about  its  obliteration, 
and  Avith  this  view  they  invented  improved  instruments. 

Dr.  Carte’s  compressors  are  seen  in  the  annexed  Avood-cuts.  Fig.  91 
shows  an  instrument  for  the  cure  of  femoral  and  popliteal  aneurism, 
10 


146 


THE  INDICATIONS  ANSWERED  BY  BANDAGES. 


F>g-  91.  Fig.  92. 


Carte’s  compressor  for  femoral  and  popliteal  aneurism.  Carte's  compressor  for  aneurisms  of  the 


upper  extremities. 


and  Fig.  92  one  for  aneurism  of  the  upper  extremities.  Fig.  93  is 
Iloey’s  clamp.  With  these  instruments,  each  having  but  a single 
pad,  the  compression  may  be  conveniently  applied  to  any  part  of 

the  course  of  an  artery;  but  as  this  can- 
FiS-  93,  not  be  borne  long,  in  conducting  the  treat- 

ment of  a case  it  will  be  necessar}T  to  use 
two  of  the  instruments  at  the  same  time  to 
alternate  the  pressure  upon  different  points. 
This  object  is,  however,  better  attained  with 


Fig.  94. 


Gibbous’  modification  of  Charriere’s  compressor. 


Hoey’s  clamp. 


the  compressor  of  Charrfere,  as  modified  by  Dr.  Gibbons,  of  Phila- 
delphia, which  consists,  as  represented  in  the  figure  (Fig.  94),  of  a long, 
broad,  and  concave  metallic  plate  or  gutter,  which  is  applied  to  the 
under  part  of  the  limb,  and  has  attached  to  its  side  three  steel  semi- 
circles spanning  half  of  the  limb,  and  bearing  at  their  extremities 
little  pads,  moved  by  screws.  When  the  apparatus  is  in  use  one  of 


THE  INDICATIONS  ANSWEKED  BY  BANDAGES.  147 

these  pads  must  be  screwed  down  upon  the  artery  so  as  to  interrupt 
the  flow  of  blood  through  it,  and  kept  there  as  long  as  the  patient  can 
bear  the  compression  comfortably.  When  it  causes  uneasiness,  the 
next  pad  is  to  be  screwed  down  and  the  first  one  removed ; we  con- 
tinue in  this  manner  to  alternate  them  during  the  treatment.  In  a 
case  of  ulnar  aneurism  I employed  the  following  instrument,  which 
possesses  a good  deal  more  steadiness  than  Charri&re’s : — 

First,  two  well-tempered  steel  rings,  of  suitable  diameter,  were 
selected,  and  connected  by  two  metallic  bars,  keeping  the  rings  from 
each  other  at  the  distance  of  the  shoulder  from  a point  just  above  the 
olecranon.  One  of  these  bars  had  a width  of  two  inches,  was  concave, 
and  fitted  to  the  outside  of  the  limb ; the  other  was  narrower,  and 
supported  three  pads  at  equal  distances  of  its  length,  at  the  ends  of 
long  screws  working  through'  it ; this  bar  was  also  movable,  to  corre- 
spond to  the  course  of  the  brachial  artery,  and  could  be  secured  at 
either  end  by  thumb-screws.  This  apparatus,  covered  with  buckskin, 
is  ready  for  use,  and,  when  properly  adjusted,  pressure  is  brought  to 
bear  upon  the  artery  by  the  pads  being  alternately  screwed  against 
it,  or,  what  I think  better,  by  bringing  them  all  down  lightly ; for  the 
force  necessary  to  interrupt  the  flow  of  blood  in  the  artery  is  thus 
distributed  among  the  three  pads,  and  hence  a third  part  only  of  it  is 
exercised  on  any  one  point  of  the  skin  at  once. 

In  many  cases  of  aneurism  the  patient’s  health  is  much  shattered, 
and  then  the  compressor  may  be  applied  night  and  morning,  allowing 
him  the  intervening  time  to  take  exercise.  In  my  case,  the  patient 
learned  how  to  manage  the  instrument,  and  carried  it  about  with 
him  concealed  in  his  coat  sleeve. 

The  success  attending  this  mode  of  treatment  has  been  truly  gratify- 
ing, and  justifies  us  always  in  giving  it  a patient  trial  before  a serious 
operation  is  undertaken.  Compression  for  a few  hours  has  sufficed  in 
some  cases  to  cause  the  fibrin  of  the  blood  to  be  deposited  in  the  sac 
in  such  quantities  as  to  convert  it  into  a solid  tumor,  while  in  others 
several  weeks  are  generally  required  to  effect  this  good  result.  The 
way  compression  acts  in  curing  aneurism  is  by  retarding  the  blood  in 
the  aneurismal  sac,  where  it  deposits  fibrin,  layer  after  layer,  until 
this  is  either  obliterated  or  its  cavity  is  reduced  to  a very  small 
channel  through  which  the  blood  flows. 

The  treatment  of  ulcers  had  long  remained  in  an  unsatisfactory 
state  until  Baynton,  an  English  surgeon,  in  1797,  introduced  his 
plan  of  curing  them  by  means  of  compression  with  adhesive  strips. 
According  to  the  statistics  of  Duchatelet,  the  average  time  required 
by  the  old  method  in  an  observation  of  690  cases  was  fifty-two  days ; 
while,  by  compression,  that  period  had  been  diminished  by  a half; 
indeed,  Yelpeau  asserts  that  he  has  seen  a large  number  of  ulcers 
cured  by  adhesive  strips  in  fifteen  or  twenty  days,  that  had  resisted 
all  other  methods.  As  has  already  been  stated,  Baynton  used  a plaster 
containing  six  drachms  of  resin  to  the  pound  of  lead  plaster ; and  his 
method  of  applying  it  was  as  follows  (Fig.  95) : “ Several  strips  of  ad- 
hesive plaster,  about  two  inches  in  breadth,  and  sufficiently  long  to  pass 
around  the  limb  and  leave  an  end  of  about  four  or  five  inches,  were 


148  THE  INDICATIONS  ANSWERED  BY  BANDAGES. 


taken;  also  several  longitudinal  compresses  made  of  soft  calico;  and 
a calico  roller  about  three  inches  in  breadth  and  varying  from  four  to 
six  yards  in  length,  according  to  the  size  of  the  limb.  One  of  these 
strips  is  to  be  applied  to  the  sound  side  of  the  limb,  opposite  the  in- 
ferior part  of  the  ulcer,  so  that 
the  lower  edge  may  be  placed 
about  an  inch  below  the  lower 
edge  of  the  sore,  and  the 
ends  drawn  over  the  lower 
part  of  the  ulcer,  with  as 
much  gradual  extension  as 
the  patient  can  conveniently 
bear ; the  other  strips  must 
"be  applied  in  the  same  man- 
ner, each  above,  and  in  con- 
tact with,  the  other,  until  the 
whole  surface  of  the  sore  and 
the  limb  is  covered  from  one 
inch  below  to  two  or  three 
inches  above  the  affected  part. 
The  whole  leg  should  then 
be  covered  equally  with  the 
longitudinal  compresses,  and 
the  roller  applied  around  the 
limb  from  the  toes  to  the  knee  with  as  much  firmness  as  the  patient 
can  support.  One  or  two  circulars  of  the  roller  should  be  first  passed 
around  the  ankle-joint,  then  as  many  round  the  foot,  as  will  cover  and 
support  every  part  of  it  except  the  toes,  and  the  same  continued  up 
the  limb  as  far  as  the  knee ; the  roller  should  be  carried  from  the 
ankle  upwards  in  doloires,  as  many  reverses  being  made  as  the  parts 
require,  in  order  that  each  turn  may  be  flat  upon  the  limb.  Should 
the  parts  be  much  inflamed  or  the  suppuration  very  abundant,  the 
applications  are  to  be  wetted  frequently  with  cold  spring  water.  The 
patient  may  take  exercise,  if  he  pleases,  as  this  will  be  found  to  alle- 
viate the  pain  and  tend  to  accelerate  the  cure.  The  bandage  ought  to 
be  daily  applied  soon  after  rising  in  the  morning,  when  the  parts  are 
most  free  from  tumefaction ; and  the  force  with  which  the  ends  of  the 
plasters  are  drawn  over  the  limb  gradually  increased  as  the  parts 


Fig.  95. 


return  to  their  natural  state  of  ease  and  sensibility.”  Wheu  it  is 
necessary  to  remove  this  bandage,  the  blunt  point  of  one  of  the  blades 


THE  INDICATIONS  ANSWERED  BY  BANDAGES.  149 


of  a pair  of  scissors,  such  as  is  represented  in  Fig.  96,  may  be  passed 
under  the  strips  from  below  upwards,  upon  the  side  opposite  to  that 
on  which  the  ulcer  is,  and  the  bandage  cut  through  its  entire  length. 
It  ought  to  have  been  stated  that,  before  the  dressings  are  applied,  the 
leg  must  be  scrupulously  shaved  and  cleansed,  that  no  secretion  may 
get  between  the  plaster  and  skin  to  cause  irritation  or  excoriation. 
The  tendo- Achilles  may  be  protected  from  pressure  by  a piece  of  soap 
plaster  spread  on  leather,  or,  as  suggested  by  Cutler,  by  a piece  of 
thin  sheet-lead.  Should  the  strips  produce  erythema,  excoriation,  or 
inflammation,  they  must  be  discontinued  for  two  or  three  days,  and 
recourse  be  had  to  emollients  until  the  above  disagreeable  accompani- 
ments be  removed.  The  pus  coming  in  contact  with  the  lead-plaster 
sometimes  produces  a black  discoloration  of  the  surface,  which  is,  of 
course,  entirely  independent  of  the  condition  of  the  ulcer,  and  may 
be  removed  easily  with  a little  soap  and  warm  water,  when  the  sore, 
if  everything  is  going  on  well,  will  present  a healthy  red  color,  and 
granulations  becoming  firmer  and  disposed  to  cicatrize. 

In  cases  of  syphilis,  where  there  is  that  kind  of  spreading  ulcera- 
tion which  creeps  under  the  skin  of  the  groin  in  every  direction,  there 
is  no  better  dressing  than  long  strips  of  adhesive  plaster ; their 
centres  being  placed  over  the  sores,  the  upper  ends  carried  around  the 
pelvis,  and  the  lower  ones  around  the  upper  part  of  the  thigh  between 
it  and  the  scrotum. 

Yelpeau  recommends  compression  with  adhesive  strips  in  burns. 
He  says:  “For  a burn  of  the  first  degree,  an  application  of  strips 
supported  by  a bandage  slightly  compressing,  and  which  may  be  re- 
newed from  the  fourth  to  the  eighth  day,  is  quite  sufficient.  If  the 
burn  is  of  the  second  degree,  that  is,  with  phlyctenulae  and  without 
phlegmonous  tumefaction,  I cause  the  separated  cuticle  to  be  removed, 
and  cleanse  off  the  exuded  matters.  The  strips  are  then  applied,  and 
the  cure  generally  takes  place  at  the  end  of  the  second  dressing,  and 
sometimes  of  the  first,  almost  always  of  the  third ; if  it  has  not  been 
effected  by  the  fourth,  this  dressing  must  be  abandoned.  If  there  is 
engorgement  and  tendency  to  erysipelas,  I commence  by  combating 
these  symptoms  by  means  of  emollient  cataplasms,  or  bleedings,  and 
then  apply  the  strips.  If  the  burn  is  of  the  third  degree,  that  is,  with 
alteration  and  destruction  of  the  surface  of  the  cutis,  we  proceed  as  in 
the  preceding  case,  and  the  cure  is  not  the  less  certain ; only  it  exacts 
from  ten  to  twenty  days.  When  the  burn  is  yet  deeper,  when  it 
involves  the  entire  thickness  of  the  dermoid  tissue,  the  strips,  not 
being  able  to  prevent  the  necessary  destruction  of  the  parts  by  the 
elimination  of  the  eschar,  are  of  no  use  until  after  the  removal  of  this 
latter,  until,  in  fact,  after  the  cleansing  of  the  ulcer.  In  other  respects, 
their  application  to  burns  is  subject  to  the  same  rules  as  for  the  treat- 
ment of  ulcers.” 

This  author  has  also  applied  the  same  treatment  to  phlegmon,  in- 
flamed varicose  tumors,  ganglionic  tumors,  and  scrofulous  ulcers  of 
the  neck  after  their  burrowings  and  loose  edges  have  been  destroyed 
by  the  acid  nitrate  of  mercury,  and  to  chronic  pains  and  other  affec- 
tions of  the  joints. 


150  THE  INDICATIONS  ANSWERED  BY  BANDAGES. 

In  ganglionic  tumors,  when  the  patient  will  not  submit  to  the  ope- 
ration of  violently  rupturing  the  cyst  with  the  back  of  a book  or 
other  appropriate  instrument,  a spring  compressor  may  be  had  re- 
course to.  f 

M.  Gariel  recommends  an  ingenious  instrument  when  a uniform 
and  gentle  compression  is  required.  It  consists  of  a little  India-rubber 
bag  furnished  with  a tube  and  stopcock.  In  applying  it,  the  bag  is 
first  emptied  entirely  of  air  and  bound  over  the  part  to  be  compressed 
by  a few  turns  of  a roller.  Then,  by  blowing  into  the  tube,  the  sack 
is  distended  and  exerts  pressure  upon  the  parts  beneath  it,  and  the 
degree  of  compression  may  be  varied  at  pleasure  without  disturbing 
the  bandage. 

To  M.  Fricke,  of  Hamburg,  is  due  the  credit  of  having  first  called 
attention  to  the  advantages  of  compression  with  adhesive  strips 
in  orchitis  and  epididymitis.  This  dressing  (Fig.  97)  may  be  applied 
in  the  following  manner : Shave  the  hair  from  the  scrotum  and 
cleanse  it  thoroughly,  then  seize  the  diseased  testicle  and  force  it 
to  the  bottom  of  the  scrotum,  and,  taking  a strip  of  adhesive  plaster 
about  half  an  inch  wide  and  seven  or  eight  inches  long,  according  to 
the  amount  of  swelling,  apply  its  middle  to  the  back  part  of  the 
scrotum  and  above  the  gland,  and  bring  its  extremities  forwards  and 
cross  them  in  front,  taking  care  that  they  lie  evenly 
upon  the  skin,  to  fix  the  testicle  in  this  position. 
Successive  strips  are  then  applied,  each  overlapping 
half  the  width  of  its  predecessor,  changing  their 
direction  as  you  proceed  towards  the  lower  part  of 
the  scrotum  that  this  may  be  covered  evenly,  until 
the  whole  organ  is  uniformly  compressed ; and 
finally  the  bandage  is  finished  by  passing  two  or 
three  strips  circularly  about  the  tumor  to  confine 
the  ends  of  the  vertical  strips.  If  there  is  much 
inflammatory  engorgement,  this  dressing  should  be 
preceded  by  the  application  of  a few  leeches  and 
saline  purgatives.  The  adhesive  strips  should  be 
renewed  as  often  as  they  become  loose  by  the  sub- 
sidence of  the  swelling. 

M.  Recamier  advised  compression  in  the  treat- 
ment of  cancerous  tumors.  His  plan  was  to  use 
disks  of  agaric,  of  sufficient  size  to  cover  the  dis- 
Fricke’s  plan  or  treating  easec[  par^  interposed  between  the  turns  of  a roller 
oicinns.  bandage.  The  disks  were  of  different  sizes,  and 

piled  one  upon  another,  in  the  shape  of  a truncated  cone  with  its  apex 
downwards,  to  the  height  of  from  two  and  a half  to  three  inches. 
When  the  diseased  surface  presented  ulcerated  nodules,  a little  cone 
of  agaric  was  placed  upon  each  of  them,  and  these  were  then  covered 
by  a larger  piece  of  the  same  material.  The  outlines  of  a part  will 
readily  suggest  in  what  shape  the  agaric  should  be  formed.  Although 
we  cannot  expect  much  benefit  from  the  plan  in  genuine  cases  of  can- 
cerous disease,  yet  in  non-malignant  tumors  or  swellings  of  any  sort 
where  a uniform  and  elastic  compression  may  be  advisable,  it  will 
be  a useful  one. 


Fig.  97. 


THE  INDICATIONS  ANSWERED  BY  BANDAGES. 


151 


Dilatation  is  nothing  but  compression  exercised  from  within  out- 
wards, and  has  many  useful  applications  in  the  treatment  of  narrowed 
canals  and  orifices. 

The  lachrymal  canals  are  sometimes  diminished  in  diameter  by 
chronic  inflammation,  and  require  dilatation  by  instruments  in  order 
that  the  tears  may  pass  into  the  nose  along  their  natural  channels  instead 
of  constantly  streaming  over  the  cheek,  which  they  will  do  if  these 
passages  are  occluded  from  any  cause,  constituting  what  is  known  as 
stillicidium,  and  which  must  be  distinguished  from  the  same  condition 
of  things  arising  from  epiphora  or  an  excessive  secretion  of  tears. 

In  stricture  of  the  oesophagus,  dilatation  is  also  indicated,  and  is 
effected  by  bougies  of  various  kinds,  gum-elastic,  metallic,  waxed 
cloth,  &c.  When  the  location  of  the  stricture  has  been  made  out  by 
the  explorer  (a  small  curved  brass  rod  mounted  with  an  ivory  ball), 
the  bougie  may  be  introduced  cautiously  into  the  oesophagus,  and 
passed  through  its  narrowed  part,  and  permitted  to  remain  a few 
minutes.  The  operation  should  be  performed  at  first  once  every  four 
or  five  days,  and  as  the  parts  become  somewhat  tolerant  of  the  pre- 
sence of  the  bougie,  it  may  be  repeated  more  frequently.  The  compres- 
sion acts  by  stimulating  the  absorbents  to  take  up  the  plastic  matter 
deposited  in  the  mucous  and  submucous  tissues  of  the  oesophagus. 

In  contraction  of  the  canal  of  the  neck  of  the  uterus,  either  when 
it  is  congenital  or  proceeds  from  disease  subsequently  established 
in  that  part,  dilatation  may  be  accomplished  by  the  persevering  use 
of  bougies,  as  will  be  explained  further  on. 

Short  silver  tubes,  about  four  inches  long  and  of  different  sizes,  from 
a quarter  of  an  inch  in  diameter  to  an  inch  and  a half,  are  used  to  dilate 
a contracted  vagina.  One  of  these  tubes  well  oiled  may  be  passed  into 
that  canal,  and  retained  there  three  or  four  hours  at  a time  by  a reten- 
tive bandage,  such  as  is  employed  to  retain  the  female  catheter. 

But  it  is  in  narrowing  of  the  urethra,  or  stricture,  that  the  greatest 
number  of  plans  for  exercising  compression  from  within  outwards 
have  been  suggested.  The  dilatation  varies  in  its  effects  according  to 
the  manner  in  which  it  is  employed;  when  gradual  and  gentle,  the 
stricture  yields  almost  imperceptibly,  while  a more  violent  and  sudden 
compression  may  give  rise  to  inflammation  of  the  urethra,  neck  of 
the  bladder,  or  the  prostate  gland.  It  is  accomplished  by  means 
of  certain  instruments  called  bougies,  which  are  made  of  silver, 
silvered  steel,  lead,  tin,  waxed  cloth,  gum  elastic,  gutta  percha,  or  wax, 
according  to  the  wishes  or  necessities  of  the  surgeon.  Some  import- 
ance has  been  attached  to  the  shapes  of  their  points,  some  of  which  are 
cylindrical,  others  conical,  and  some,  again,  olive  shaped  or  fusiform. 
As  to  the  method  of  manipulating  with  these  instruments,  we  shall 
defer  its  consideration  until  we  come  to  speak  of  the  catheterism  of 
the  male  urethra.  Some  special  instruments  for  making  dilatation 
have  also,  at  different  times,  been  suggested.  Mr.  Arnott’s  dilator  con- 
sisted of  a membranous  tube  which  he  introduced  into  the  urethra 
and  distended  with  water.  M.  Grariel  invented  a dilator  made  of  India- 
rubber,  in  the  shape  of  an  ordinary  bougie,  with  its  parietes  thinned 
at  a certain  place  near  its  point,  and  which  expanded  into  a fusiform 


152  THE  INDICATIONS  ANSWERED  BY  BANDAGES. 


sac  when  air  was  driven  into  the  tube.  A still  more  ingenious  con- 
trivance was  brought  forward  by  a French  surgeon,  consisting  of  two 
small  steel  wires  continuous  at  their  distal  extremities  in  a rounded 
point,  and  placed  side  by  side,  and  curved  like  an  ordinary  catheter. 
One  of  the  proximal  ends  is  fixed  firmly  to  a handle  and  the  other  to 
a screw  moving  upon  its  axis,  an  arrangement  which  permits  the  sur- 
geon to  introduce  the  instrument  as  a Iso.  1 bougie  (French  scale),  and 
subsequently  to  expand  it  by  separating  the  wires  by  the  action  of  the 
screw  to  the  size  of  a No.  30  bougie,  without  removing  it  from  the 
urethra.  Somewhat  similar  to  the  preceding  is  the  instrument  shown 

in  Fig.  98.  In  using  this  dilator  it 


Fig.  98. 


is  introduced  closed,  and  when  the 
stricture  is  passed  by  simply  turning 
the  screw  the  blades  are  expanded  by 
the  little  pin  connecting  them  together 
at  the  point  marked  B. 

Care  should  be  taken  to  close  the 
blades  carefully  before  an  attempt  is 
made  to  withdraw  the  instrument,  as 
otherwise  the  mucous  membrane  is  apt 
to  be  caught  between  them  and  torn,  as 
I have  seen  in  two  instances. 

A much  safer  dilator,  in  inexpe- 
rienced hands,  will  be  found  in  the 
compound  circular  catheter  of  Dr.  A. 
Buchanan,  of  Glasgow.  It  consists 
of  a small  round- pointed  probe,  over 
which  silver  tubes  of  different  sizes 


Fig.  99. 


THE  INDICATIONS  ANSWERED  BY  BANDAGES.  153 


Fig.  100. 


are  slipped  one  upon  another,  as  seen  in  Fig.  99.  In  guiding  this 
instrument  along  the  membranous  and  prostatic  portions  of  the 
nrethra,  Dr.  Buchanan  advises  the  finger  to  be  retained  in  the  rectum. 

Mr.  Sheppard,  of  England,  employs  a dilator  (Fig.  100)  composed 
of  a fine  catheter  grooved  upon  one  of  its  sides;  in 
the  groove  a small  wire  or  traveller  slides,  armed  at 
its  point  with  an  oval  metallic  tip ; for  the  dilata- 
tion of  the  stricture  a number  of  tips  of  various 
sizes  will  be  required. 

Mr.  Wakely,  of  London,  devised  the  instruments 
seen  in  the  annexed  wood-cuts.  Fig.  102  is  a very 
small  catheter,  which  is  used  to  pass  the  stricture; 
into  the  catheter,  the  slender  steel  rod  (Fig.  101)  is 
introduced  and  screwed  fast,  the  two  together  form- 
ing a directing -rod.  Over  this  rod  are  slipped  a 
series  of  silver  conical  tubes  (Fig.  103),  or  India- 
rubber  tubes  (Fig.  101)  tipped  with  metallic  buttons 
to  facilitate  their  introduction.  The  tubes  vary  in 
size  from  one  just  large  enough  to  ensheath  the  rod 
to  the  largest,  which  is  equal  to  a No.  10  bougie. 

Compression  plays  an  important  part,  also,  in  shepPard!=  dilator 


Fig.  101.  Fig.  102.  Fig.  103. 


Fig.  104. 


Wakely’s  dilators  for  stricture  of  the  urethra. 

the  action  of  numerous  orthopedic  bandages  and 
be  seen  when  we  come  to  study  that  subject. 


154  THE  INDICATIONS  ANSWERED  BY  BANDAGES. 

In  most  of  the  instances  of  the  use  of  compression  which  we  have 
hitherto  cited,  that  agency  was  exerted  over  some  extent  of  the  sur- 
face, and  intended  to  be  conservative;  but  there  is  another  sort  of 
compression  which  is  only  brought  to  bear  upon  a very  restricted 
space,  a line,  and  hence  sometimes  called  linear  compression,  and  is 
always  designed  to  destroy  the  life  of  the  parts  below  the  point  to 
which  it  is  applied.  Under  this  head  fall  ligatures  and  the  ecraseur. 

Ligatures. — These  act  in  two  modes,  according  to  the  way  in 
which  they  are  applied ; if  the  ligature  is  drawn  as  tight  as  possible 
the  moment  it  is  put  on,  and  the  constriction  is  complete,  the  vascular 
supply  to  the  parts  beneath  it  is  cut  off,  and  they  consequently  soon 
lose  their  vitality,  become  dark  colored,  and  fall  off,  leaving  an 
ulcerating  surface  behind ; should  the  ligature,  however,  not  be  drawn 
so  tight  as  this,  but  only  sufficiently  to  interrupt  and  diminish  their 
vascular  supply,  the  parts  below  then  shrivel  up  gradually,  and  as 
the  thread  makes  its  way  into  the  tissues,  cicatrization  follows  close 
in  its  rear,  and  by  the  time  the  constricted  portion  is  separated,  the 
surface  beneath  it  is  nearly  healed.  Ligatures  are  made  of  various 
substances — annealed  iron  or  silver  wire,  packthread,  catgut,  seagrass, 
or  silk,  and  are  applied  either  with  the  fingers  or  with  special  instru- 
ments called  porte-ligatures,  or  knot-tighteners.  Care  must  be  taken 
that  the  ligatures  be  of  sufficient  strength  to  bear  the  amount  of  con- 
striction  necessary  to  be  made,  without  breaking  or  unduly  stretching, 
and,  in  applying  them,  to  cut  through  the  skin  previously,  that  it  may 
not  be  included  in  the  loop,  unless,  as  sometimes  happens,  the  skin 
is  diseased,  or  the  tumor  of  small  size,  when  this  preliminary  step 
will  not  be  necessary. 

There  are  several  modes  of  applying  a ligature ; when  the  morbid 
growth  is  small,  such  as  naevi  materni,  hemorrhoids,  &c.,  the  thread 
may  be  tied  directly  around  its  base  or  pedicle,  and,  if  necessary 
to  prevent  its  slipping,  two  hare-lip  pins  may  be  previously  passed 
through  it,  at  right  angles  to  each  other,  having  entered  them 
through  the  sound  skin  about  an  eighth  of  an  inch  from  the  tumor 
and  emerging  at  a corresponding  distance  upon  the  other  side.  Should 
the  base  of  the  tumor,  however,  be  larger,  a needle  armed  with  a 
double  thread  may  be  passed  through  it ; the  threads  being  then 
separated,  each  of  them  should  be  tied  around  its  corresponding 
pedicle.  Very  large  tumors  require  to  be  tied  in  three  or  four 
portions.  The  best  needle  for  this  purpose  is  made  of  untempered 
steel  with  an  eye  near  its  point,  which  should  be  rather  blunt,  that 
any  bloodvessels  in  the  parts  through  which  it  passes  may  not  be 
punctured  by  it.  To  divide  the  tumor  in  three  portions,  arm  this 
needle  with  a double  thread  and  thrust  it  through  its  base  in  one 
direction;  enter  it  again  and  pass  it  back  in  the  opposite  direction,  and 
finally  through  a third  time  as  in  the  first  instance,  taking  care  that 
the  points  of  transfixion  be  at  equal  distances  from  each  other ; one 
thread  only  of  the  first  loop  is  cut,  and  both  of  the  threads  of  the 
second  loop,  which  will  make  five  pairs  of  ends.  By  thrusting  a 
needle  with  a double  thread  through  the  base  of  a tumor  in  one  direc- 
tion, then  a second  time  in  a direction  at  right  angles  to  the  first,  and 
finally  cutting  one  of  the  threads  of  the  loop  thus  formed,  we  will 


THE  INDICATIONS  ANSWERED  BY  BANDAGES. 


155 


divide  a tumor  in  four  portions ; and  if  two  of  the  three  pairs  of  ends 
are  first  knotted  together,  by  drawing  strongly  upon  the  third  pair 
and  tying  them,  its  whole  base  will  be  constricted. 

Mr.  Fergusson  has  improved  upon  this  plan  of  constricting  naevi. 
He  prefers  a common  surgical  needle  armed  with  a double  thread  ; 
this  is  thrust  through  the  base 
of  the  tumor,  and  one  of  the 
threads  upon  that  side  cor- 
responding with  the  needle 
is  cut  in  two  about  three 
inches  from  the  eye;  the 
needle  is  then  threaded  with 
the  end  of  that  portion  of  the 
divided  thread  upon  the  op- 
posite side  of  the  tumor  and 
again  passed  through  the  lat- 
ter at  right  angles  to  its  first 
course.  When  the  threads 
are  disengaged  from  the  nee- 
dle there  will  be  two  pairs  of 
ends,  which  are  to  be  drawn 
tight  and  tied  together  in  two  knots.  In  this  manner,  as  seen  in  the 
cut  (Fig.  105),  two  figures  of  8 are  formed  by  the  threads  at  right 
angles  to  each  other. 

When  the  tumor  is  of  such  a form  that  it  cannot  be  divided  into 
separate  portions  by  the  above  plan,  the  surgeon  may  have  recourse 
to  the  method  recommended  by  Mr.  Erichsen : “ A long  triangular 
needle  is  threaded  on  the  middle  of  a whip-cord,  about  three  yards 
in  length;  one  half  of  this  is  stained  black  with  ink,  the  other  half 
is  left  uncolored.  The  needle  is  inserted  through  a fold  of  the  sound 
skin,  about  a quarter  of  an  inch  from  one  end  of  the  tumor,  and 


Fig.  105. 


Fig.  106. 


Erichsen’s  method  of  ligating  vascular  tumors. 


transversely  to  the  axis  of  the  same.  It  is  then  carried  through, 
until  a double  tail,  at  least  six  inches  in  length,  is  left  hanging  from 


156  THE  INDICATIONS  ANSWERED  BY  BANDAGES. 

the  point  at  which  it  entered ; it  is  next  carried  across  the  base  of  the 
tumor,  entering  and  passing  out  beyond  its  lateral  limits,  so  as  to  leave, 
as  shown  in  Fig.  106,  a series  of  double  loops  about  nine  inches  in 
length  at  each  side.  Every  one  of  these  loops  should  be  made  about 
three-quarters  of  an  inch  apart,  including  that  space  of  the  tumor, 
and  the  last  loop  should  be  brought  out  through  a fold  of  healthy 
integument  beyond  the  tumor.  In  this  way  we  have  a series  of 
double  loops,  one  white  and  the  other  black,  on  each  side,  as  in  Fig. 
106.  All  the  white  loops  should  now  be  cut  on  one  side  and  the 
black  loops  on  the  other,  leaving  hanging  ends  of  thread  of  corres- 
ponding colors. 

“The  tumor  may  now  be  strangulated  by  drawing  down  and  knot- 
ting firmly  each  pair  of  white  threads  on  one  side  and  each  pair  of 
black  ones  on  the  other.  In  this  way  the  tumor  is  divided  into  seg- 
ments, each  of  which  is  strangulated  by  a noose  and  a knot ; by  black 
nooses  and  white  knots  one  side,  by  white  nooses  and  black  knots  on 
the  other,  as  in  Fig.  107.” 

Subcutaneous  ligature  is  effected  by  entering  a curved  needle  armed 
with  a thread  at  any  point  of  the  base  of  a tumor  between  it  and  the 
skin.  Thrusting  it  as  far  as  possible,  shove  its  point  through  the 
skin,  and  withdraw  the  needle ; enter  its  point  a second  time  at  this 
puncture,  and  pass  it  along  again  in  its  original  course  until  it  emerges 
at  the  first  puncture,  when  the  needle  is  pulled  out,  and  the  ends  of 
the  ligature  tied. 

When  the  loop  of  the  ligature  cannot  be  placed  around  the  tumor 
conveniently,  if  at  all,  with  the  fingers,  as  happens  in  polypus  of  the 
nose  and  uterus,  recourse  must  be  had  to  porte-ligatures  or  knot- 
tighteners,  the  simplest  of  which  is  the  double  canula  of  Levret ; it 


Fig.  108. 


Double  cajiula. 


consists  of  two  metallic  tubes  immovably  connected  together,  and 
open  at  both  ends,  to  one  of  which  two  little  rings  are  soldered,  one 
upon  each  side.  To  use  the  instrument,  a piece  of  silver  wire  of 
sufficient  length  is  passed  into  the  tubes  so  as  to  form  a loop,  one  of 
its  ends  being  twisted  around  one  of  the  rings,  while,  with  the  other 
end,  the  size  of  the  loop  is  regulated  until  the  surgeon  may  have 
satisfactorily  arranged  it,  when  that  extremity  must  be  drawn  tight, 
and  also  twisted  around  the  second  ring.  Graefe’s  knot-tightener 
“ consists  of  a shaft  of  steel  pierced  at  one  extremity  by  an  opening 
through  which  pass  the  two  ends  of  the  knot  already  applied ; at  the 
other  extremity  is  a vice  which,  in  moving  to  one  side  or  the  other, 
elevates  or  depresses  a movable  screw,  to  which  are  firmly  attached 
the  two  ends  of  the  ligature.  One  single  turn  of  the  vice  suffices  to 
loosen  or  tighten  the  constriction.  This  instrument  combines  great 
simplicity  and  force.”  The  knot-tightener  of  Roderic,  as  modified  by 
Mayor,  is  formed  of  a chaplet  of  small  balls,  representing  a flexible 
column,  through  which  the  ligature  passes  by  small  holes  in  each  ball. 


THE  INDICATIONS  ANSWERED  BY  BANDAGES. 


157 


The  ecraseur  lineciire  is  an  instrument  intended  to  make  the  slow 
section  of  the  tissues,  somewhat  in  the  manner  of  a ligature.  It  was 
recently  invented  by  M.  Chassaignac.  It  consists  of  a strong  metallic 
tube  through  which,  for  a part  of  its  length,  a long  screw  works,  bear- 
ing at  its  extremity  a sort  of  chain  loop,  which  projects  some  distance 


beyond  the  tube ; the  screw  is  moved  by  a handle,  and  draws  in  the 
loop  with  a slow  and  steady  but  irresistible  force ; the  inner  margin 
of  the  chain  is  provided  with  a blunt  and  saw-like  edge  which  bruises 
and  crushes  through  the  tissues.  This  action  of  the  ecraseur  is  one  in 
which  consists  all  its  merits,  for  it  is  well  known  that  arteries  divided 
by  crushing  or  tearing  bleed  very  little.  For  the  purpose  of  operating 
upon  tumors  of  the  uterus,  or  in  localities  where  a straight  stem  could 
not  be  used  with  advantage,  if  at  all,  the  end  of  the  instrument  may 
be  unscrewed  and  a long  curved  beak  substituted  in  its  place.  The 
division  of  the  tissues  must  be  effected  slowly,  to  avoid  hemorrhage; 
the  time  occupied  in  an  operation  will  vary,  according  to  the  size  and 
vascularity  of  the  morbid  growth,  from  five  to  twenty  minutes ; the 
handle  of  the  instrument  may  be  made  to  make  one  complete  revolu- 
tion from  every  two  to  twenty  seconds.  If  the  tumor  has  a very 
broad  base,  it  may  be  ligated  previous  to  the  application  of  the  chain 
of  the  ecraseur.  The  after-dressings  are  the  same  as  after  operations 
in  the  ordinary  way.  The  cases  in  which  the  Ecraseur  has  been  used 
with  success  are,  removal  of  the  penis,  testicle,  tongue,  neck  of  the 
uterus,  and  a large  number  of  vascular  and  other  tumors.  It  has 
even  been  suggested  to  remove  limbs  with  it,  by  first  dividing  the 
bone  with  a special  instrument,  and  then  cutting  through  the  soft 
tissues  with  the  chain  loop.  But  this  is  certainly  inferior  to  the  ordi- 
nary method  of  amputation,  and  all  such  efforts  to  render  the  applica- 
bility of  any  instrument  universal,  will  in  time  bring  it  into  discredit 
even  in  those  cases  in  which  it  is  really  useful. 

M.  Maisonneuve  employs  a number  of  wire  threads  twisted  together 
according  to  the  volume  and  resistance  of  the  parts  to  be  divided, 


158 


CLASSIFICATION  OF  BANDAGES. 


instead  of  the  articulated  chain.  The  tension  of  the  wires  is  regu- 
lated by  a windlass  similar  to  that  of  Graefe’s  knot-tightener  already 
described. 


SECTION  IY. 

CLASSIFICATION  OF  BANDAGES. 

The  classification  of  bandages  was  for  a long  time  involved  in  the 
greatest  confusion,  for  the  reason  that  their  nomenclature  was  entirely 
unsystematic  and  without  method.  Some  of  them  were  called  after  the 
names  of  their  inventors,  some  according  to  their  form,  whilst  others 
bore  names  expressive  of  their  use  or  their  elegance : thus  we  have 
had  the  Rhomb  of  Hippocrates,  the  Tolus  of  Diodes,  the  Discrimen, 
the  Kiaster,  and  the  Thais. 

Some  attempts  were  made  to  found  a classification  upon  the  mode 
of  action  of  the  bandages ; and  such  terms  as  uniting,  dividing,  com- 
pressing, &c.,  were,  therefore,  applied  to  them ; but  these  divisions, 
as  we  have  already  shown,  are  valueless  for  the  purposes  of  a nomen- 
clature, as  the  same  bandage  may  belong  to  three  or  four  classes  at 
the  same  time. 

Gerdy  proposed,  in  his  excellent  Treatise  upon  Bandaging,  a classifi- 
cation based  upon  the  geometric  figures  formed  by  the  different 
bandages ; and  it  is  doubtless  the  best  yet  suggested,  and  has  been 
adopted  in  most  of  the  recent  treatises  upon  bandages.  This  is  the 
classification  we  intend  to  follow  in  this  work,  so  modified,  however, 
as  to  include  all  the  bandages  and  apparatus  coming  within  the  scope 
we  have  proposed  to  ourselves.  The  following  table  will  enable  the 
reader  to  see  the  whole  classification  at  a glance : — 

SIMPLE  BANDAGES. 

Circular  Bandages. 

Form  circular  turns  about  a part. 

Oblique  Bandages. 

Form  oblique  turns  about  a part. 

Spiral  Bandages. 

Form  spiral  turns  called  doloires. 

Figure  of  8,  or  Crossed  Bandages. 

Form  turns  resembling  the  figure  8 or  X. 

Knotted  Bandages. 

Form  knots  at  certain  parts  of  their  course. 

Recurrent  Bandages. 

Form  turns  running  backwards  and  forwards  between  two  points. 

Handkerchief  Bandages. 

Are  formed  from  handkerchiefs,  towels,  or  pieces  of  muslin. 

Invaginated  Bandages. 

Are  composed  of  pieces  with  slits  in  them  to  receive  corresponding  tails. 
COMPOUND  BANDAGES. 

T Bandages. 

Form  a figure  resembling  the  letter  T. 

Cruciform  Bandages. 

Form  a figure  resembling  a cross. 

Sling  Bandages. 

Are  formed  of  pieces  split  at  their  ends. 

Suspensory  Bandages. 

Form  a sort  of  purse. 


BANDAGES  FOR  THE  HEAD. 


159 


Sheath  Bandages. 

Form  a sheath. 

Laced,  Buckled,  and  Elastic  Bandages. 

Are  formed  with  buckles,  lacings,  and  elastic  cloth. 

MECHANICAL  BANDAGES. 

Orthopraxic  Bandages  : Bandages  for  Fractures  : Bandages  for  Dislo- 
cations. 

These  bandages  involve,  to  a greater  or  less  degree,  the  application  of  the 
mechanical  powers. 


CHAPTER  VIII. 

SPECIAL,  OR  REGIONAL  BANDAGING. 

SECTION  I. 

BANDAGES  FOR  THE  HEAD. 


SIMPLE  BANDAGES. 

Circular  Bandages. 

Of  the  forehead  and  eyes. 

Crossed  Bandages. 

The  monocle. 

The  binocle. 

The  single  crossed  bandage  for  the  lower  jaw. 
The  double  crossed  bandage  for  the  lower  jaw. 
The  crossed  bandage  of  the  head. 

The  crossed  bandage  of  the  head  and  neck. 
Knotted  Bandages. 

The  knotted  bandage  of  the  head. 

Recurrent  Bandages. 

The  recurrent  bandage  of  the  head. 
Handkerchief  Bandages. 

The  triangular  bandage  of  the  head. 

The  quadrilateral  bandage  of  the  head. 
Invaginated  Bandages. 

The  invaginated  bandage  of  the  lips. 

COMPOUND  BANDAGES. 

T Bandages. 

T bandage  of  the  head  and  ears. 

The  double  T bandage  of  the  nose. 

The  T bandage  of  the  head. 

The  double  T bandage  of  the  head. 

The  T bandage  of  the  mouth. 

Crucial  Bandages. 

The  crucial  bandage  of  the  head. 

Sling  Bandages. 

The  six-tail  bandage  of  the  head. 

The  four-tail  bandage  of  the  chin. 

The  mask. 

Sheath  Bandages. 

The  sheath  bandage  of  the  nose. 

The  sheath  bandage  of  the  tongue. 


160 


SPECIAL,  OE  REGIONAL  BANDAGING. 


MAYOR’S  BANDAGES. 

The  circular  cravat. 

The  occipitofrontal  triangle. 

The  fronto-occipital  triangle. 

The  fronto-oculo-occipital  triangle. 

The  bis-oculo-occipital  triangle. 

The  occipito-mental  triangle. 

The  fronto-cervico-labial  triangle. 

The  facial  triangle. 

The  occipito-auricular  triangle. 

RIGAL’S  BANDAGES. 

The  cap. 

The  half-cap. 

The  simple  capeline. 

The  fixed  capeline. 

The  Arabic  capeline. 

The  shepherd’s  sling. 

The  ocular  triangle. 

A.  Simple  Bandages. 

§ 1.  Circular  Bandages. 

Circular  bandages  are  applied  to  the  different  parts  of  the  body  by 
means  of  the  roller,  tbe  turns  of  which  sometimes  overlap  each  other 
by  half  or  two-thirds  of  their  width,  at  others  the  whole  width,  and 
surround  the  part  at  right  angles  to  its  axis.  They  act  with  energy 
and  directness  upon  the  parts  beneath,  and,  therefore,  demand  watch- 
ful attention,  during  their  employment,  that  the  circulation  be  not 
arrested,  and  mortification  thereby  ensue ; for  this  reason  they  are 
not  well  adapted  for  making  compression,  but  are  used  generally  as 
a retentive  means,  either  to  secure  the  initial  extremity  of  a roller  or 
to  retain  dressings.  The  circular  bandages  may  be  applied  to  any 
part  of  the  body  possessing  a nearly  uniform  diameter. 

The  Circular  Bandage  for  the  Forehead  and  Eyes.  Compo- 
sition.— A piece  of  muslin  one  yard  long  and  nine  inches  wide,  folded 
lengthwise  in  four  that  its  lateral  edges  may  be  placed  within  the 
folds ; or  a roller  two  yards  long  by  two  inches  broad. 

Application. — Place  the  centre  of  the  oblong  compress  upon  the 
forehead,  carry  its  extremities  horizontally  around  the  head,  cross 
them  over  the  occiput ; then  bring  them  forwards  and  fasten  them  to 
the  bandage  over  the  temples  with  pins. 

If  the  roller  is  employed,  place  its  initial  extremity  upon  any  point 
of  the  circumference,  secure  it  with  three  or  four  circular  turns,  and 
pin  the  terminal  end. 

By  making  a T-shaped  incision  in  the  middle  of  the  compress, 
about  half  an  inch  from  its  folded  margin,  the  upper  part  of  the  T 
being  horizontal  and  the  vertical  one  corresponding  to  the  anterior 
edge  of  the  nose,  the  bandage  may  be  made  to  cover  the  eyes;  the 
nose  passing  through  the  incision  will  prevent  the  bandage  slipping 
down  ; this  is  called  the  bandeau. 

Use. — To  confine  dressings  upon  the  forehead,  temples,  and  eyes 
as  well  as  to  shield  the  latter  organs  from  the  glare  of  light.  To 


BANDAGES  FOR  THE  HEAD. 


161 


absorb  any  rays  of  light  that  may  penetrate  the  folds  of  the  bandage, 
a piece  of  some  dark-colored  and  light  material,  as  silk  or  crape,  is 
sometimes  employed  in  its  composition.  When  no  compression  is 

Fig.  110. 


needed  upon  the  eyes,  but  the  object  is  simply  to  ward  off  the  injurious 
action  of  light,  a green  silk  shade  is  commonly  employed ; with  a 
linen  flap  attached  to  the  bandeau,  and  hanging  over  the  eye,  or 
with  the  arrangement  seen  in  Fig.  110,  cold  water  may  be  applied. 


2. 


Crossed  Bandages. 


The  Crossed  Bandage  of  One  Eye,  or  Monocle. — 1st  Variety. 

Composition. — A single-headed  roller  five  yards 
long  and  two  inches  wide.  F!S-  m- 

Application. — Place  the  initial  extremity  upon 
any  point  of  the  circumference  of  the  head  and 
secure  it  by  two  circular  turns,  passing  from  left 
to  right,  if  the  object  is  to  cover  the  right  eye, 
and  in  the  reverse  direction  to  cover  the  left ; 
when  the  cylinder  reaches  the  occiput  at  the  end 
of  the  last  horizontal  turn,  depress  it  sufficiently 
to  pass  under  the  ear  of  the  side  affected,  over  its 
corresponding  cheek  to  the  inner  canthus  of  the 
diseased  eye  (it  is  not,  however,  to  interfere  with 
the  vision  of  the  sound  eye) ; then  to  the  forehead, 
where  a reverse  is  made  to  alter  the  direction  of  Monocle, 

the  roller  to  a horizontal  line ; follow  this  direc- 
tion by  making  a circular  turn  to  fasten  the  reverse  upon  the  forehead, 
continue  around  to  the  occiput,  depress  the  roller  to  pass  again  beneath 
the  ear  and  over  the  cheek  of  the  diseased  side  to  the  forehead,  where 
a second  reverse  is  made,  then  cover  this  by  a horizontal  turn  ; pursue 
this  course,  alternating  circular  with  reverse  turns  three  or  four  times, 
and  terminate  the  bandage  by  two  horizontal  turns  around  the  head. 
Another  mode  of  applying  the  monocle  is,  instead  of  making  reverse 
turns  upon  the  forehead,  to  carry  the  roller  over  the  parietal  pro- 
tuberance, and  to  alternate  the  circular  and  oblique  turns  thus  formed. 
(Fig.  111.)  The  different  turns  of  this  bandage  may  be  secured,  with 
pins,  to  a muslin  cap,  which,  will  render  it  much  more  secure. 

11 


162 


SPECIAL,  OR  REGIONAL  BANDAGING. 


Use. — To  maintain  dressings  upon  the  eyes,  and  to  make  com- 
pression upon  their  globes ; for  the  first  purpose  it  is  not  so  well 
adapted  as  the  bandeau,  and  it  is,  besides,  apt  to  slip. 

2 d Variety  of  the  Monocle. 

Composition. — A roller  eight  yards  long  and  two  inches  wide,  and 
suitable  compresses. 

Application. — If  the  right  eye  is  to  be  bandaged,  place  a compress 
upon  it;  permit  three  or  four  feet  of  the  initial  end  of  the  bandage 
to  hang  free  from  the  right  horizontal  ramus  of  the  lower  jaw,  carry 
the  roller  over  the  corresponding  cheek  and  eye,  over  the  left  parietal 
eminence  to  the  nape  of  the  neck,  then  depress  it  so  as  to  pass  under 
the  right  ear  and  around  the  neck  to  confine  the  free  portion  of  the 
bandage  hanging  below  the  jaw ; then  to  the  occiput  and  over  the 
right  ear  to  the  forehead,  where  the  free  portion  which  has  been 
brought  up  to  this  point  is  reflected  over  it,  and  then  permitted  to 
hang  in  front  of  the  jaw  again ; continue  around  the  head  to  the 
occiput,  under  the  right  ear  and  around  the  neck,  when  the  free  por- 
tion is  crossed  a second  time,  reflected  over  it  and  carried  up  to  the 
level  of  the  forehead,  to  be  covered  by  the  next  circular  turn  : pursue 
the  same  course  until  four  turns  of  the  roller  cross  the  eye,  and  then 
terminate  the  bandage  by  circular  turns. 

Use. — This  form  of  the  monocle  is  quite  solid,  and  well  adapted  for 
making  pressure  upon  the  globe  of  the  eye. 

The  Crossed  Bandage  of  Both  Eyes,  or  Binocle. — lsi  Variety  ; 
with  a single-headed  roller. 

Composition. — A roller  eight  }rards  long  and  two  inches  wide. 

Application. — Having  laid  over  the  eyes  the  appropriate  compresses, 
place  the  initial  extremity  of  the  bandage  upon  the  forehead  and  con- 
fine it  by  two  circular  turns,  arriving  at  the  occiput ; the  roller  being 
carried  from  right  to  left,  pass  below  the  left  ear,  and  over  its  corre- 
sponding cheek  and  eye  to  the  forehead,  where  a reverse  is  to  be  made 
to  give  the  roller  a horizontal  direction  around  the  head ; arriving  in 
front  it  meets  the  turn  covering  the  left  eye ; here  another  reverse  is 
made,  and  the  direction  of  the  roller  changed,  so  that  it  now  passes 
over  the  right  eye  under  the  corresponding  ear  to  the  occiput : make 
three  or  four  of  these  oblique  turns,  and  finish  the  bandage  with  an 
equal  number  of  circulars  to  consolidate  the  whole. 

Use. — To  retain  dressings  upon  the  eyes ; but  it  is  inferior,  for  this 
purpose,  to  the  simple  bandeau — causing  pain  by  its  pressure,  and 
being,  besides,  heavy  aud  heating  to  the  parts  below. 

2 d Variety  of  the  Binocle ; with  a double-headed  roller. 

Composition. — A double-headed  roller  eight  yards  long  by  two 
inches  wide — one  of  the  cylinders  being  somewhat  larger  than  the 
other. 

Application. — Place  the  body  of  the  roller  upon  the  forehead,  and 
carry  the  two  cylinders,  one  upon  either  side,  beneath  the  ears  to  the 
nape  of  the  neck,  cross  them,  and  at  the  same  time  reverse  the  lower 
turn  upon  the  upper;  then  bripg  them  forward  under  the  ears,  over 
the  cheeks  and  eyes,  to  the  forehead,  where  the  rollers  are  crossed 
and  carried  over  the  parietal  eminences  to  the  occiput,  to  be  again 


BANDAGES  FOE  THE  HEAD. 


163 


crossed  and  reversed  as  before.  The  same  course  is  to  be  gone  over 
three  or  four  times,  or  until  the  smaller  roller  is  exhausted,  and  both 
eyes  are  neatly  covered  in.  Complete  the  bandage  by  circulars  with 
the  remaining  unexpended  portion  of  the  second  roller,  and  pin  its 
extremity.  This  will  be  found  not  so  easily  disturbed  as  the  previous 
bandage,  executed  with  a single-headed  roller. 

Use. — The  same  as  the  former  bandage. 

The  Single  Ceossed  Bandage  op  the  Lowee  Jaw.  Composi- 
tion.— A roller  six  yards  long  by  two  inches  wide. 

Application. — After  having  adjusted  the  appropriate  compresses, 
place  the  initial  extremity  of  the  bandage  upon  the  forehead,  and 
cover  it  by  two  horizontal  turns  passing  from  left  to  right  if  the 
disease  or  injury  is  upon  the  left  side,  and  vice  versa ; arriving  at  the 
nape  of  the  neck,  the  roller  is  made  to  take  a course  under  the  ear  of 
the  sound  side,  under  the  chin  and  over  the  vertex,  passing  between 
the  external  angle  of  the  eye  and  ear  back  to  the  chin ; three  vertical 
turns  are  made  in  this  manner  around  the  head  and  chin,  and  when 
the  roller  at  the  end  of  the  third  turn  arrives  at  the  side  of  the  jaw, 
carry  it  beneath  the  chin  and  make  a circular  turn  around  the  neck 
to  the  occiput,  and  ascend  obliquely  across  the  side  of  the  head  to  the 
forehead  to  make  a circular  turn  around  this.  This  will  bring  the 
roller  again  to  the  nape  of  the  neck,  from  which  it  comes  beneath  the 
ear  and  around  the  chin  to  the  occiput,  the  upper  margin  of  the  turn 
being  just  below  the  mouth ; repeat  again  this  turn,  which  should 
overlap  three-fourths  of  its  predecessor,  and  continue  the  roller  around 
the  side  of  the  neck  under  the  chin  up  over  the  cheek  across  the  vertex 
to  the  chin  again,  when  another  turn  is  made  in  a similar  manner, 
and  from  its  termination  under  the  chin  conduct  the  cylinder  around 
the  neck  to  make  a circular  turn  of  this  part,  whence  it  should  pass 
obliquely  across  the  occiput  to  the  forehead  to  finish  the  bandage  by 
' two  circular  turns  around  the  head. 

In  fracture  of  the  neck  of  the  inferior  maxillary  bone,  it  is  disad- 
vantageous to  have  the  chin  pressed  upon  by  the  circular  turns,  as  it 
causes  the  lower  fragment  to  be  thrown  forwards  and  upwards.  So 
that,  in  such  cases,  all  those  turns  of  the  bandage  after  the  third  verti- 
cal turn  around  the  head  and  chin  should  be  omitted ; and,  instead, 
the  roller  is  reversed  over  one  of  the  temples  and  the  bandage  finished 
by  two  circular  turns  around  the  forehead. 

Use. — This  modification  of  the  bandage  is  employed  in  the  treat- 
ment of  fractures  of  the  lower  jaw,  but  in  some  cases,  when  the  object 
is  to  exert  compression  upon  the  side  of  the  neck,  the  former  is  pre- 
ferable. 

■ The  Double  Ceossed  Bandage  of  the  Lowee  Jaw. — ls£  Variety. 

Composition. — A single- headed  roller  seven  yards  long  by  two 
inches  wide. 

Application. — Confine  the  initial  extremity  of  the  bandage  upon  the 
forehead  by  two  circular  turns,  passing  from  the  nape  of  the  neck 
under  the  right  ear  around  the  neck  to  the  front  of  the  left  ear,  con- 
duct the  roller  across  the  top  of  the  head  to  the  occiput,  under  this  to 
the  crown  of  the  head  again  where  it  crosses  the  previous  turn  and 


164 


SPECIAL,  OR  REGIONAL  BANDAGING. 


passes  down  in  front  of  tire  right  ear  and  under  the  chin,  in  front  of 
the  left  ear  across  the  top  of  the  head  to  the  nape ; make  two  more 
such  turns,  and  at  the  end  of  the  third  one  the  roller  is  to  be  conducted 
under  the  chin,  around  the  neck,  under  the  left  ear,  to  the  occiput, 
from  thence  round  the  forehead  to  the  nape,  and  around  the  neck  to 
the  occiput  again.  From  this  point  make  two  circular  turns  around 
the  front  of  the  chin,  and  then  pass  around  the  neck,  and  return  again 
to  the  place  of  starting,  when  the  roller  is  carried  across  the  top  of  the 
head  down  in  front  of  the  left  ear,  under  the  chin  over  the  right  side 
of  the  face  and  to  the  top  of  the  head  again,  where  it  crosses  the  pre- 
vious turn  and  goes  on  to  the  occiput.  Go  again  from  this  point  over 
the  head,  down  the  left  side  of  the  face,  under  the  chin  and  over  the 
right  cheek,  across  the  crown  to  the  nape  of  the  neck,  and  complete 
the  bandage  by  two  circular  turns  around  the  forehead. 

Use. — This  was  formerly  often  employed  in  the  treatment  of  frac- 
ture of  the  neck  of  the  inferior  maxillary  bone ; but  the  same  objection 
can  be  urged  against  this  as  against  the  former,  that  is,  throwing  the 
lower  fragments  forward. 

It  answers  well  to  make  pressure  upon  the  parotid  region  after 
suitable  compresses  have  been  placed  over  it. 

2d  Variety;  with  a double-headed  roller. 

Composition. — A double-headed  roller  eight  yards  long  by  two 
inches  broad,  with  unequal  cylinders. 

Application. — Place  the  body  of  the  bandage  upon  the  forehead, 
carry  the  cylinders  back  under  the  ears  and  cross  them  over  the  nape 
of  the  neck,  reversing  the  lower  one  upon  the  upper ; then  bring  them 
forwards  and  cross  them  under  the  chin  so  that  they  may  pass  over 
the  vertical  ramus  of  the  inferior  maxillary  bone  to  the  top  of  the 
head  where  the  turns  cross,  the  inferior  one  being  reversed  upon  the 
superior ; from  this  point  continue  to  the  nape,  where  another  cross 
and  a reverse  are  to  be  made,  and  the  cylinders  conducted  to  the  chin, 
crossed  and  continued  over  the  angles  of  the  lower  jaw  to  the  top  of 
the  head,  crossed  and  reversed  here  and  then  carried  back  to  the  nape. 
This  course  is  to  be  gone  over  three  times  in  this  manner,  and  the 
turns  secured  by  a circular  around  the  forehead,  by  that  cylinder  with 
which  the  reverse  has  been  made  over  the  back  of  the  neck ; at  the 
latter  point  they  will  again  start,  go  round  the  chin,  and  are  crossed 
(the  lowest  turn  being  reversed  upon  the  upper  to  prevent  any  wrink- 
ling) and  brought  to  the  neck  in  order  to  make  another  turn  similar 
to  the  preceding.  This  brings  the  two  cylinders  again  to  the  occiput 
to  cross  and  pass  around  the  neck  to  the  chin,  where  they  are  again 
crossed  and  conducted  up  over  the  cheeks  to  the  top  of  the  head,  then 
crossed  and  brought  to  the  nape,  crossed  there  and  passed  round  the 
neck  to  be  crossed  under  the  chin  and  run  over  the  cheeks  to  the 
vertex,  and  crossed  again  to  go  to  the  nape.  Here  one  of  the  cylinders 
being  exhausted,  the  bandage  is  terminated  by  two  circular  turns 
around  the  forehead  with  the  remaining  roller. 

Use. — This  is  a much  firmer  bandage  than  the  one  made  with  the 
single-headed  roller ; it  is  employed  in  the  same  cases. 


BANDAGES  FOR  THE  HEAD. 


165 


The  Crossed  Bandage  of  the  Head.  Composition. — A smgle- 
heaclecl  roller  six  yards  long  by  two  inches  wide. 

Application. — If  the  right  temple  is  to  be  covered  in,  place  above  the 
right  eye  the  initial  extremity  of  the  bandage  and  confine  it  by  two 
circular  turns ; arriving  behind  the  right  ear,  reverse  the  roller  and 
carry  it  perpendicularly  beneath  the  chin  over  the  left  side  of  the  face 
and  top  of  the  head  to  the  place  of  beginning : in  this  manner  make 
four  or  five  vertical  turns,  or  as  many  as  may  be  necessary  to  cover 
in  the  temple.  In  the  last  turn,  when  the  roller  comes  to  the  right 
ear,  reverse  and  carry  it  horizontally  around  the  head  twice  or  three 
times,  when  the  bandage  is  complete. 

Use. — This  is  a very  simple  bandage  for  retaining  dressings  upon 
the  temple,  ear,  and  angle  of  the  jaw. 

The  Crossed  Bandage  of  the  Head  and  Neck.  Composition. — 
A single-headed  roller  six  yards  long  by  two  inches  wide. 

Application.— Place  the  initial  extremity  of  the  bandage  upon  the 
occiput,  and  make  two  circular  turns  around  the  forehead,  and  when 
the  roller  comes  to  a level  with  the  ear,  carry  it  obliquely  over  the 
nape  and  under  the  angle  of  the  lower  jaw ; make  a complete  circuit 
of  the  neck,  returning  under  the  angle  of  the  jaw  of  the  opposite 
side  so  as  to  cross  the  previous  turn  over  the  occiput,  and  continue 
around  the  forehead ; repeat  this  twice  or  three  times,  and  terminate 
the  bandage  by  circular  turns  around  the  head. 

Use. — To  retain  dressings  upon  the  back  of  the  neck,  as  after  the 
use  of  a seton  or  blister. 


§ 3.  Knotted  Bandages. 

The  Knotted  Bandage  of  the  Head.  Composition. — A double- 

headed roller  seven  yards  long  by  two  inches  wide,  wound  in  two 
unequal  heads;  a pyramidally  graduated  compress,  and  a small  bit  of 
adhesive  plaster. 

Application. — Close  the  wound  in  the  temple  with  the  adhesive 
plaster  and  place  over  this  the  compress  with  its  apex  upon  the 
wound.  An  assistant  holds  the  compress  steady,  while  the  surgeon 
with  a cylinder  in  each  hand  places  the  body  of  the  roller  over  it  and 
makes  a horizontal  turn  to  the  opposite  temple,  when  the  cylinders 
pass  each  other,  the  lower  being  reversed  upon  the  upper  one,  and 
are  brought  back  again  to  the  wound,  over  which  a packer’s  knot  is 
made  by  twisting  them  upon  themselves  so  that  one  of  the  cylinders 
passes  over  the  vertex  and  the  other  under  the  chin  to  the  sound 
temple,  at  which  point  they  are  reversed  upon  each  other  as  before. 
When  brought  to  the  wound  another  knot  is  made  with  the  rollers, 
and  then  they  are  conducted  circularly  around  the  head.  In  this 
manner  form  five,  six,  or  more  knots  side  by  side  over  the  wound, 
when  the  small  cylinder  will  be  exhausted,  and  the  bandage  will  be 
completed  by  two  circular  turns  with  the  larger  one. 

Use. — To  make  compression  in  wounds  of  the  temporal  artery 
accompanied  with  hemorrhage.  This  bandage  should  be  carefully 
watched,  as  it  often  exercises  injurious  pressure  upon  the  margins  of 
the  lower  jaw. 


166 


SPECIAL,  OR  REGIONAL  BANDAGING. 


Recurrent  Bandages. 


The  Eecurrent  Bandage  of  the  Head.  (Fig.  112.)— Is*  Variety; 
with  single-headed  roller. 

Composition. — A single-headed  roller  five  yards  long  by  two  inches 
wide. 

Application. — Confine  the  initial  extremity  at  the  forehead,  or  upon 
either  temple,  by  two  circular  turns,  just  above  the  eyebrows,  and  when 

the  roller  comes  to  the  nape  reverse 
the  bandage  and  hold  the  reverse 
with  the  left  fore-finger,  while  the 
roller  is  carried  along  the  median 
line  to  the  forehead,  where  another 
reverse  is  to  be  made  and  the  roller 
carried  backwards,  making  a turn 
alongside  of  the  former,  and  over- 
lapping a third  of  its  width.  Re- 
verse again  at  nape,  and  make 
another  turn  on  the  opposite  side 
of  the  middle  one  and  overlapping 
it ; continue  thus  in  making  these 
recurrent  turns,  first  on  one  side  and 
then  on  the  other,  until  the  upper 
part  of  the  head  is  entirely  cov- 
ered in,  when  the  bandage  is  to  be 
finished  by  two  or  three  circulars 
around  the  forehead. 

Use. — To  confine  dressings  upon 
the  scalp,  and  to  exercise  a mild  degree  of  pressure  upon  it  where 
such  is  necessary. 

This  bandage  is  easily  deranged,  and  not  so  solid  as  when  made  with 
the  double-headed  roller. 

2d  Variety ; with  a double-headed  roller. 

Composition.— A.  double-headed  roller  seven  yards  long  by  two 
inches  wide,  and  wound  into  two  unequal  heads. 

Application. — Place  the  body  of  the  bandage  upon  the  forehead, 
conduct  the  two  cylinders  backwards,  above  the  ears,  to  the  nape  of 
the  neck,  where  they  are  crossed,  and  the  lower  roller  reversed  over 
the  upper  one,  and  brought  forward,  in  the  median  line  of  the  head,  to 
the  forehead,  where  the  second  roller,  brought  horizontally  around, 
crosses  and  confines  it  to  the  part.  The  roller  that  has  made  the  ver- 
tical turn  is  carried  again  to  the  occiput  to  make  another  turn  along- 
side of  the  first,  and  covering  a third  of  its  width.  At  this  point 
also  the  horizontal  roller  fastens  it  to  the  occiput,  and  permits  it  to 
pass  forwards  again  to  form  a turn  upon  the  other  side  of  the  median 
one.  The  head  is  to  be  covered  in  this  manner  by  recurrent  turns, 
first  on  one  side  and  then  on  the  other,  when,  the  smaller  cylinder  being 
exhausted,  the  large  one  completes  the  bandage  by  two  or  three  circu- 
^r  turns.  To  render  it  more  secure,  the  terminal  end  may  be  carried, 
vertically,  over  the  head,  from  ear  to  ear,  and  pinned  to  the  reverses. 

Use. — The  same  as  in  the  preceding  case. 


Fig.  112. 


BANDAGES  FOR  THE  HEAD. 


167 


§ 5.  Handkerchief  Bandages. 

The  Triangular  Bandage  of  the  Head.  Composition.  — A 
square  piece  of  muslin  or  a handkerchief  of  an  appropriate  size  folded 
into  a triangle. 

Application.— Place  the  base  of  the  triangle  under  the  occipital  pro- 
tuberance and  let  its  apex  hang  over  the  face,  then  bring  the  two 
extremities  to  the  forehead  and  cross  them  over  the  apex,  when  they 
are  to  be  conducted  to  the  nape  and  tied  together,  or  pinned ; the  apex 
of  the  triangle  is  now  to  be  reflected  over  the  top  of  the  head  and 
pinned. 

Use. — This  is  a very  simple  and  easily-applied  bandage  for  confining 
dressings  upon  the  scalp. 

The  Quadrilateral  Bandage  of  the  Head.  Composition. — A 
piece  of  muslin  one  yard  long  and  two  feet  wide,  and  folded  length- 
wise in  such  a manner  that  one  side  shall  be  three  inches  broader  than 
the  other. 

Application. — Place  the  middle  of  the  bandage  upon  the  top  of  the 
head,  with  the  narrow  side  upwards,  and  the  folded  border  posterior,  so 
that  the  lower  margin  of  the  broader  side  will  hang  about  the  level  of 
the  point  of  the  nose,  and  the  lower  margin  of  the  other  at  the  level  of 
the  eyebrows.  The  anterior  angles  of  the  narrow  side  are  now  to  be 
drawn  down  and  tied  beneath  the  chin,  and  the  other  two  anterior 
angles  folded  backwards  over  the  former  and  tied,  or  pinned  under  the 
occiput.  The  two  posterior  angles  of  the  folded  border  are  then  to  be 
drawn  down  neatly  and  folded  in  between  the  cheeks,  and  that  part  of 
the  bandage  covering  them. 

Use. — This  is  an  excellent  bandage  for  retaining  dressings  upon  the 
head,  or  for  protecting  the  scalp,  but  it  is  heavy  and  heating. 

§ 6.  Invaginated  Bandages. 

The  Invaginated  Bandage  for  Vertical  Wounds  of  the 
Lips  (Fig.  113).  Composition. — 1st.  A double-headed  roller  three  yards 
long  and  three-quarters  of  an  inch  wide. 

2d.  Two  prismatic  compresses,  each  an 
inch  and  a half  long  by  an  inch  wide, 
and  of  a thickness  proportionate  to  the 
prominence  of  the  cheek.  3d.  An  oblong 
compress  a yard  and  a quarter  long  by 
an  inch  and  a half  wide. 

Application. — Let  an  assistant  hold 
the  compresses  half  an  inch  from  the 
corners  of  the  mouth,  while  the  surgeon 
lays  the  centre  of  the  oblong  compress 
upon  the  top  of  the  head  and  brings  its 
two  extremities  under  the  chin.  Now 
place  the  body  of  the  roller  upon  the 
forehead,  carry  the  two  cylinders  above 
the  ears,  cross  them  on  the  nape,  and 
bring  them  forwards  under  the  ears  over  the  graduated  compresses  to 


Fig.  113. 


The  invaginated  bandage  for  vertical 
wounds  of  the  lips. 


168 


SPECIAL,  OR  REGIONAL  BANDAGING. 


the  upper  lip ; then  slip  one  of  them  through  a slit  made  in  the  band 
a few  inches  below  the  other  one,  when  both  rollers  are  again  crossed 
over  the  nape,  brought  forward  over  the  lip,  and  returned  to  the  nape, 
at  which  point  they  are  left  a moment  until  the  ends  of  the  oblong 
compress  have  been  reflected  up  and  crossed  upon  the  vertex  and  its 
extremities  pinned  over  the  temples,  when  the  cylinders  are  again 
taken  hold  of  and  the  bandage  completed  by  circular  turns  around 
the  forehead  until  they  are  exhausted. 

Use. — To  approximate  the  edges  of  vertical  wounds  of  the  lips,  so 
as  to  prevent  traction  upon  the  twisted  suture. 

B.  Compound  Bandage. 

§ 1.  T Bandages. 

The  T bandages  are  those  which  resemble  in  some  manner  the  letter 
of  that  name,  and  are  single,  when  one  vertical  strip  is  attached  to  a 
horizontal  one ; or  double,  when  two  vertical  strips  are  so  arranged. 

The  T Bandage  of  the  Head  and  Ears.  Composition. — A roller 
three  yards  long  and  an  inch  and  a half  wide ; about  fourteen  inches 
from  its  initial  extremity  the  end  of  another  roller  is  sewed  of  the 
same  length  and  width,  with  an  oval  opening  cut  into  it  correspond- 
ing with  the  ear. 

Application. — Place  the  initial  extremity  of  the  horizontal  roller 
upon  that  part  of  the  circumference  of  the  head  so  that  the  vertical 
one  will  come  in  the  line  of  the  ear  to  be  dressed,  and  confine  it  by  a 
circular  turn ; then  with  the  vertical  band  make  two  or  three  vertical 
turns  around  the  vertex  and  chin  until  it  is  exhausted ; terminate  the 
bandage  by  fixing  the  whole  by  two  or  three  circulars. 

Use. — To  retain  dressings  upon  the  auricular,  temporal,  and  mastoid 
regions. 

The  Double  T Bandage  of  the  Nose  (Fig.  114).  Composition. — 
A strip  of  muslin  one  yard  long  and  half  an 
inch  wide ; upon  the  middle  of  this  one  sew 
two  other  pieces  of  the  same  width  and  half  a 
yard  long,  at  an  acute  angle. 

Application. — That  portion  intervening  be- 
tween the  two  vertical  strips  is  placed  upon 
the  upper  lip  beneath  the  nose,  while  the  roller 
of  the  horizontal  band  is  carried  around  the 
head,  beneath  the  ears,  and  tied  over  the  nape 
of  the  neck.  The  other  two  strips  are  to  be 
carried  over  the  top  of  the  head,  crossing  each 
other  at  the  root  of  the  nose;  having  reached 
the  occiput  they  are  passed  under,  and  re- 
flected over,  the  horizontal  strip,  and  pinned. 
Use. — To  retain  dressings  upon  the  nose. 
The  T Bandage  of  the  Head.  Composi- 
tion.— A strip  of  muslin  two  yards  long  and  two  inches  wide,  to  which, 
at  about  a third  of  its  length,  is  attached,  at  right  angles,  another  strip 


Fig.  114. 


Double  T bandage  of  the  nose. 


BANDAGES  FOB  THE  HEAD. 


169 


one  yard  long  and  of  the  same  width  as  the  previous  one.  The  hori- 
zontal hand  is  to  be  rolled  up  in  two,  unequal  cylinders. 

Application. — Place  the  point  of  junction  of  the  two  bands  over 
the  forehead  with  the  vertical  one  lying  along  the  median  line  of  the 
head  to  the  occiput,  at  which  point  the  other  bandelette  crosses  it, 
allowing  it  again  to  be  reflected  to  the  forehead,  where  it  is  secured 
by  two  or  three  circular  turns. 

A double  T may  be  easily  applied  in  the  same  manner  by  using 
two  vertical  strips  instead  of  one. 

Use. — A very  light  bandage  for  confining  dressings  to  the  scalp. 

The  T Bandage  of  the  Mouth.  Composition. — A strip  of  muslin, 
four  and  a half  yards  long  and  an  inch  and  a half  wide,  having  sewed 
to  one  of  its  margins,  about  a foot  and  a half  from  its  end,  a second 
piece  a foot  and  a half  long  and  of  the  same  width ; at  the  point  of 
junction,  the  vertical  bandelette  is  to  be  split  up  an  inch  and  a half  or 
two  inches,  and  a triangular  piece  removed  from  it;  immediately  below 
this  an  oval  opening  is  to  be  made  corresponding  with  the  mouth. 

Application. — The  nose  is  thrust  through  the  triangular  opening 
and  the  oval  aperture  is  placed  over  the  mouth,  so  that  the  vertical 
band  presses  along  the  sagittal  suture  to  the  occiput,  where  the  hori- 
zontal band  coming  from  the  mouth  under  the  ears  crosses  it ; it  is 
now  reflected  upwards  along  the  centre  of  the  head,  and  pinned  to 
the  previous  turn.  The  two  ends  of  the  horizontal  portion  are  taken 
hold  of  and  crossed,  the  inferior  being  reversed  upon  the  upper  one, 
and  brought  to  the  forehead  where  the  bandage  is  completed  by  two 
circular  turns. 

Use. — This  bandage  will  be  found  very  convenient  for  retaining 
dressings  upon  the  mouth  and  cheeks. 

§ 2.  Crucial  Bandages. 

The  Cbucial  Bandage  of  the  Head.  Composition. — A bandelette 
one  yard  long  and  from  one  and  a half  to  two  and  a half  inches  wide 
has  sewed  to  it,  about  six  inches  from  one  of  its  ends,  another  banda- 
lette  two  yards  long  and  one  and  a half  inch  wide  at  right  angles  with 
it,  forming  a sort  of  cross,  having  a long  and  short  arm,  the  latter 
being  about  a foot  in  length. 

Application. — Place  the  juncture  of  the  bands  over  the  temple,  upon 
which  the  dressings  have  been  laid,  with  the  long  one  horizontal; 
now  conduct  the  vertical  band  around  the  head  and  chin,  and  pin  them 
over  the  apex,  and  then  complete  the  bandage  by  circular  turns  around 
the  forehead  with  the  horizontal  band. 

Use. — The  crucial  bandage  of  the  head  is  well  adapted  by  its 
perfect  simplicity  and  lightness  to  keep  dressings  in  place  upon  the 
temples,  the  parotid  regions,  and  the  ears. 

§ 3.  Sling  Bandages. 

The  sling  bandages  are  very  simple,  and  often  very  useful  and 
efficient;  they  consist  of  a piece  of  muslin  with  both  of  its  extremities 
slit  into  a number  of  tails;  the  name  is  obtained  from  the  resemblance 
they  bear  to  the  sling  used  by  the  ancients  for  casting  stones. 


170 


SPECIAL,  OR  REGIONAL  BANDAGING. 


The  Six-Tailed  Bandage  of  the  Head  (Fig.  115) — Bandage 
OF  Galen.  Composition. — A piece  of  muslin  a yard  and  a half  long 

and  twelve  inches  wide  split  at 
lg'  each  end  into  three  tails,  the  mid- 

dle one  being  somewhat  broader 
than  the  other  two,  leaving  a 
central  portion  or  body  about 
five  inches  long. 

Application. — The  body  of  the 
bandage  is  placed  upon  the  top 
of  the  head,  and  the  middle  tails, 
with  their  edges  folded  under  to 
resemble  a triangle,  are  tied  be- 
neath the  chin.  The  two  poste- 
rior tails  are  now  reversed  upon 
these  and  also  tied  beneath  the 
chin,  while  the  two  anterior  tails 
are  conducted  backwards,  crossed 
under  the  occipital  protuberance, 
and  firmly  knotted  together  on 
the  forehead. 

Use.  — This  bandage  is  very 
simple  and  well  suited  for  retain- 
ing dressings  upon  any  portion  of  the  upper  part  of  the  head. 

The  Four-Tailed  Bandage  of  the  Head  (Fig.  116).  Composi- 
tion.— A piece  of  muslin  a yard  and  a quar- 
ter long  and  six  inches  wide,  split  at  each 
end  into  two  tails  to  within  three  inches  of 
its  centre. 

Application. — The  body  of  this  bandage 
may,  according  to  the  indications,  be  placed 
upon  the  forehead,  vertex,  or  occiput.  In  the 
first  instance,  the  anterior  tails  are  tied  be- 
hind the  head,  and  the  posterior  under  the 
chin ; in  the  second,  the  anterior  tails  are 
knotted  together  over  the  nape  of  the  neck, 
and  the  posterior  ones  in  front  under  the 
chin ; and  in  the  third  and  last,  the  anterior 
tails  are  secured  round  the  forehead  and  the 
posterior  around  the  neck. 

Use. — As  seen  above,  this  bandage  will 
answer  to  hold  any  sort  of  dressings  upon  any  portion  of  the  upper 
part  of  the  head. 

The  Four-Tailed  Bandage  of  the  Chin  (Fig.  117).  Composition. 

■ — 1st.  A piece  of  muslin  one  yard  and  a half  long  and  three  inches 
wide,  split  at  each  extremity  in  two  tails  to  within  one  inch  and 
a half  of  its  centre.  2d.  Compresses  of  suitable  size. 

Application. — Any  compresses  deemed  desirable  are  placed  upon 
the  lower  jaw  and  held  by  an  assistant,  while  the  surgeon  places  the 
body  of  the  bandage  under  the  chin,  and  conducts  its  anterior  tails 


The  six-tailed  bandage  of  the  head. 


Fig.  116. 


The  four-tailed  bandage  of  the  head. 


BANDAGES  FOB  THE  HEAD. 


171 


Fig.  117. 


The  four-tailed  bandage 
of  the  chin. 


alongside  of  the  face,  beneath  the  ears  to  the  nape  of  the  neck,  crosses 
them  here  and  ties  them  over  the  forehead.  The  posterior  tails  are 
carried  vertically  in  front  of  the  ears  to  the  top  of 
the  head  to  be  crossed  there  and  brought  beneath 
the  chin  and  tied  together. 

Use. — The  four-tailed  bandage  of  the  chin  is 
used  almost  exclusively  in  the  treatment  of  frac- 
ture of  the  lower  jaw,  and  it  answers  a very  good 
purpose  as  a temporary  dressing  in  retaining  the 
fragments  in  position.  This  is  much  less  trouble- 
some than  the  cross  bandage  of  the  chin,  and  is 
probably  quite  as  efficient. 

The  Mask.  Composition. — An  oval  piece  of 
muslin  large  enough  to  cover  the  whole  face,  with 
suitable  holes  cut  in  it  to  expose  the  eyes,  nose, 
and  mouth,  and  having  attached  to  its  superior 
border  two  pieces  of  tape  a yard  long,  and  two 
similar  pieces  to  its  lower  border. 

Application. — Lay  the  mask  over  the  face  and  carry  the  upper  tapes 
to  the  nape  of  the  neck,  cross  them  there,  then  bring  them  to  the  chin 
and  tie  them  together.  The  inferior  tapes  are  to  be  crossed  in  like 
manner  over  the  occiput  and  fastened  around  the  forehead. 

Use. — To  retain  dressings  upon  the  face  in  burns  or  other  injuries. 

§ 4.  Sheath  Bandages. 

The  Sheath  Bandage  of  the  Nose  (Epebvier).  Composition. — • 
A triangular  piece  of  muslin  of  sufficient  size  to  cover  the  nose,  with 
two  small  triangular  pieces  removed  from  its  lateral  angles,  and  the 
edges  afterwards  sewed  together ; this  forms  a sort  of  pocket,  which 
will  exactly  lodge  the  nose.  Now  cut 
from  its  lower  part  two  small  pieces 
corresponding  in  size  to  the  nostrils;  and 
to  the  apex  and  to  each  of  the  lateral 
angles  of  the  sheath  sew  a piece  of  tape 
half  a yard  long. 

Application. — Place  the  sheath  upon 
the  nose,  and  conduct  the  two  lateral 
tapes  to  the  occiput,  cross  them,  and 
finally  tie  them  over  the  forehead ; next 
carry  the  tape  fixed  to  its  apex  in  the 
course  of  the  sagittal  suture,  loop  it 
around  the  other  tapes  behind,  and  then 
reflect  it  forwards,  and  pin  it  to  the  pre- 
vious turn. 

Use.  — To  retain  topical  applications 
to  the  nose. 

The  Sheath  Bandage  of  the 
Tongue  (Fig.  118).  Composition. — A 

small  pocket  of  muslin  (a)  of  a similar 
shape  to  that  of  the  tongue  should  be 


Fig.  118. 


172 


SPECIAL,  OK  REGIONAL  BANDAGING. 


prepared  and  fastened  by  its  base  to  a piece  of  wire  shaped  like  a 
horse-shoe,  and  bent  twice  upon  itself,  so  that  it  will  clasp  the  chin. 
Fasten  a piece  of  tape  a yard  long  to  each  wire  as  it  passes  in  front  of 
the  chin. 

Application. — The  sheath  is  slipped  over  the  tongue,  and  the  wire 
fitted  to  the  chin ; then  conduct  the  two  tapes  backwards  beneath  the 
ears  to  the  nape  of  the  neck,  where  they  are  crossed,  and  afterwards 
tie  them  together  over  the  forehead. 

Use. — This  bandage  was  invented  by  Pibrac,  a French  surgeon,  to 
restrain  the  movements  of  the  tongue  in  wounds  of  that  organ. 

C.  Mayor’s  Bandages  for  the  Head. 

We  have  already  described  the  four  elementary  forms  of  all  the 
bandages  used  by  Mayor. 

The  Circular  Cravat  of  the  Head. — As  the  name  indicates,  this 
bandage  consists  of  a simple  cravat  passing  circularly  around  the  head. 

Use. — It  is  intended  to  replace  the  bandeau  and  circular  bandage 
of  the  head. 

The  Occipito-Frontal,  Fronto-Occipital,  and  the  Bi-Parietal 
Triangles. — The  fronto-occipital  triangle  consists  of  a triangular 
piece  of  muslin,  a yard  and  a quarter  at  its  base  and  seventeen  inches 
from  the  base  to  the  apex. 

Application. — Place  the  base  of  the  triangle  upon  the  forehead  above 
the  eyebrows ; draw  the  apex  over  the  top  of  the  head  to  the  back  of 
the  neck,  and  carry  the  lateral  extremities  around  the  head,  cross  them 
over  the  occiput,  then  bring  them  forward  and  pin  them  over  the  tem- 
ples. The  apex  is  passed  under  the  bandage  behind,  and  turned  back 
over  the  head  and  pinned. 

The  occipito-frontal  and  the  bi-parietal  triangles  are  used  in  the 
same  manner,  with  this  modification,  that  the  base  of  the  triangle  is 
placed  over  the  occiput  in  the  first  instance,  and  over  one  or  the  other 
temple  in  the  second. 

Use. — To  retain  dressings  upon  the  head.  These  triangles  are 
much  simpler  than  the  other  retaining  bandages  of  the  head,  as  the 
recurrent,  six-tailed,  and  square  handkerchief,  and  they  supply  their 
places  very  often  without  inconvenience. 

The  Fronto-Oculo-Occipital  Triangle.  Composition. — A trian- 
gular piece  of  muslin,  seventeen  inches  from  base  to  apex. 

Application. — Place  the  centre  of  the  triangle  upon  the  diseased  eye 
obliquely,  then  carry  the  lateral  extremities  around  the  head,  one 
below  the  ear  of  the  diseased  side  and  the  other  above  the  ear  upon 
the  opposite  side,  cross  them  behind,  and  finally  tie  them  together 
over  the  forehead.  The  apex  of  the  triangle  is  conducted  diagonally 
across  the  top  of  the  head,  passed  under  the  bandage  upon  the  side, 
and  then  reflected  back  and  pinned. 

Use. — To  replace  the  monocle. 

The  bis-oculo-occipital  triangle  may  be  made  by  disposing  another 
triangle  in  the  same  manner  upon  the  other  side,  and  is  used  as  a sub- 
stitute for  the  binocle. 


BANDAGES  FOE  THE  HEAD. 


173 


The  Occipital  Mental  Teiangle.  Composition. — A triangular 
piece  of  muslin  a yard  and  a quarter  long  and  seventeen  inches  from 
base  to  apex. 

Application. — Place  the  middle  of  the  base  of  the  triangle  upon  the 
top  of  the  head,  cross  the  lateral  extremities  under  the  chin,  and  pin 
them  over  the  sides  of  the  face.  The  apex  is  brought  forward  and 
pinned  over  either  of  the  temples. 

Use. — Employed  in  fractures  of  the  jaw  instead  of  the  crossed  band- 
ages. 

The  Feonto-Ceevico-L/Abial  Teiangle.  Composition. — A trian- 
gular piece  of  muslin  a yard  and  a quarter  long  and  seventeen  inches 
from  its  base  to  its  summit. 

Application. — Place  the  base  of  the  triangle  upon  the  forehead  and 
conduct  its  lateral  extremities  around  the  head  to  the  nape,  cross  them 
at  this  point  and  bring  them  forward  over  the  lip  where  they  may  be 
either  crossed  or  invaginated  to  regain  the  occiput;  then  fasten  the 
extremities  together.  The  apex  of  the  triangle  is  passed  beneath  the 
bandage  behind,  reflected  upwards,  and  pinned. 

Use. — After  the  operation  for  hare-lip,  to  remove  the  strain  upon  the 
suture;  it  is  intended  to  replace  the  other  more  complicated  invagi- 
nated bandages  for  this  purpose. 

The  Facial  Teiangle.  Composition. — A piece  of  muslin  a yard 
and  a quarter  long  and  seventeen  inches  from  its  base  to  its  apex, 
with  apertures  for  the  nose,  eyes,  and  mouth  made  into  it. 

Application. — Place  the  base  above  the  eyebrows,  conduct  its  lateral 
extremities  to  the  occiput,  cross  them,  and  then  bring  them  forwards 
again  to  be  tied  over  the  forehead.  Draw  the  apex  of  the  triangle 
down  over  the  face,  and  carry  it  under  the  chin,  and  finally  fasten  it 
to  that  part  of  the  bandage  over  the  neck. 

Use. — To  replace  the  mask ; it  is  employed  in  the  same  cases. 

The  Occipito  Aueiculae  Teiangle.  Composition. — A triangular 
piece  of  muslin  a yard  and  a quarter  long  and  seventeen  inches  broad. 

Application. — Place  the  base  of  the  triangle  upon  the  vertex  with 
its  apex  backwards,  conduct  its  two  lateral  tails  downwards  over  one 
or  both  ears  as  desired,  and  cross  them  under  the  chin,  when  they  are 
to  be  pinned  to  the  bandage  over  the  side  of  the  face.  The  apex 
may  be  fastened  over  either  temple. 

Use. — To  hold  dressings  upon  the  auricular,  parotid  and  maxillary 
regions,  and  as  a substitute  for  the  knotted  and  T bandages  of  the 
head. 

D.  Eigal’s  Bandages  foe  the  Head. 

The  Cap  is  simply  a triangular  piece  of  muslin,  with  its  base 
upon  the  top  of  the  head,  and  its  lateral  tails  fastened  beneath  the 
chin;  the  open  part  behind  is  closed  with  elastic  threads  passed 
through  eyelet  holes  or  loops.  Or,  again,  a common  skullcap  split 
open  behind  and  laced  in  this  manner  will  answer  the  same  purpose. 

Use. — Eetention  of  topical  applications  to  the  scalp. 

The  Half-Cap  is  a vertical  section  of  a skullcap  with  the  elastic 


174 


SPECIAL,  OR  REGIONAL  BANDAGING. 


threads  attached  to  its  margin.  It  may  he  placed  upon  the  forehead, 
occiput,  or  temples. 

Use. — Same  as  the  former.  Both  of  these  bandages  may  be  advan- 
tageously replaced  by  the  simpler  ones  of  Mayor  used  for  the  same 
purposes. 

The  Simple  Capeline  consists  of  a square  piece  of  muslin  of 
sufficient  size  to  cover  the  head  when  doubled. 

This  is  folded  once  from  side  to  side,  and  its  middle  portion  placed 
upon  the  top  of  the  head ; the  four  angles  at  each  side  are  brought 
together  and  fastened  beneath  the  chin.  The  folds  between  the  angles 
are  then  pinned  in  front  or  behind. 

Use. — Retention  of  dressings  to  the  scalp. 

The  Fixed  Capeline.  Composition. — A square  piece  of  muslin 
folded  in  a triangle. 

Application. — Place  the  base  of  the  triangle  in  the  centre  of  the 
forehead,  and  conduct  its  two  lateral  tails  beneath  the  chin,  cross 
them  there,  and  fasten  them  over  the  temples.  The  two  salient  folds 
formed  between  the  lateral  angles  and  the  apex  are  laid  down  and 
pinned ; lastly,  the  extremity  reaching  down  the  back  is  reflected 
upwards  and  pinned. 

Use. — It  serves  the  same  purpose  as  the  previous  bandage. 

The  Arabic  Capeline.  Composition. — A square  piece  of  muslin 
folded  from  side  to  side. 

Application. — Place  the  body  of  the  bandage  over  the  forehead,  with 
the  folded  side  forwards,  then  gather  up  the  two  anterior  angles  and 
hold  them  until  they  are  secured  by  tying  the  internal  angles  of  the 
posterior  border  around  the  forehead,  when  they  may  be  drawn  under 
the  chin  and  secured  with  pins. 

The  Sling  of  the  Shepherd.  Composition. — 1st,  a skullcap  of 
muslin  ; 2d,  a piece  of  muslin  six  inches  long  by  four  inches  broad  with 
two  of  its  angles  perforated  with  eyelet  holes ; 3d,  an  elastic  thread. 

Application. — Place  the  cap  upon  the  head,  and  then  surround  the 
chin  by  the  bandelette  with  the  eyelet  holes  over  the  angles  of  the 
lower  jaw.  Rest  the  middle  of  the  elastic  thread  upon  the  back  of 
the  neck,  bring  its  ends  forward  through  the  eyelet  holes,  and  pass 
them  up  over  the  top  of  the  head,  where  they  are  to  be  tied ; secure 
the  threads  at  the  side  by  two  pins. 

Use. — The  same  as  the  sling  of  the  chin. 

The  Ocular  Triangle.  Composition. — 1st,  a square  piece  of 

muslin  folded  once  from  side  to  side,  and  each  of  the  four  angles 
perforated  with  a hole ; 2d,  three  elastic  threads ; 3d,  a skullcap. 

Application. — Place  one  half  of  the  compress  obliquely  over  one 
eye  (the  right),  pin  it  to  the  edge  of  the  cap,  then  reverse  the  upper 
half  upon  this,  so  as  to  cover  in  the  other  eye,  and  leave  a triangular 
space  between  the  two  flaps  for  the  nose;  then  pin  the  remaining 
angle  of  the  folded  edge  to  the  cap.  Through  the  posterior  holes  pass 
an  elastic  thread,  running  behind  the  neck;  connect  the  anterior  holes 
by  a similar  cord,  passing  under  the  chin;  then  join  the  two  elastic 
cords  together  by  a third. 

Use. — The  same  as  Mayor’s  bandage  for  the  eye. 


BANDAGES  OF  THE  NECK  AND  TRUNK 


SECTION  II. 

BANDAGES  OF  THE  NECK  AND  TRUNK. 

SIMPLE  BANDAGES. 

Circular  Bandages. 

Circular  of  the  neck. 

Circular  of  the  chest  and  abdomen. 

Oblique  Bandages. 

Oblique  bandages  of  neck  and  axilla. 

Spiral  Bandages. 

Spiral  bandages  of  the  body. 

Crossed  Bandages. 

Posterior  figure  of  8 of  the  head  and  axillas. 

Anterior  figure  of  8 of  the  head  and  axillas. 

Figure  of  8 of  the  head  and  one  axilla. 

Figure  of  8 of  the  neck  and  axilla. 

The  spica  or  figure  of  8 of  the  shoulder  and  opposite  axilla. 
The  anterior  figure  of  8 of  the  shoulders. 

The  posterior  figure  of  8 of  the  shoulders. 

The  crossed  bandage  of  the  chest. 

The  crossed  bandage  of  one  breast. 

The-crossed  bandage  of  both  breasts. 

The  crossed  bandage  of  one  groin. 

The  crossed  bandage  of  both  groins. 

COMPOUND  BANDAGES. 

T Bandages. 

The  double  T of  the  chest  and  abdomen. 

The  anterior  double  T of  the  head  and  chest. 

The  posterior  double  T of  the  head  and  chest. 

The  double  T of  the  pelvis. 

The  T bandage  of  the  groin. 

The  Crossed  Bandage  of  the  Trunk. 

Sling  Bandages. 

The  sling  bandage  of  the  shoulder. 

The  sling  bandage  of  the  breast. 

The  sling  bandage  of  the  hip. 

Suspensory  Bandages. 

The  suspensory  of  the  breast. 

The  suspensory  of  the  testicle. 

Sheath  Bandages. 

The  sheath  of  the  penis. 

MAYOR’S  BANDAGES  FOR  THE  NECK  AND  TRUNK. 

The  cravat  of  the  neck. 

The  occipito-thoracic  triangle. 

The  fronto-thoracic  triangle. 

The  parieto-axillary  triangle. 

The  thoracico-scapular  triangle. 

The  simple  bis-axillary  cravat. 

The  compound  bis-axillary  cravat. 

The  simple  dorso-bis-axillary  cravat. 

The  compound  dorso-bis-axillary  cravat. 

The  cravat,  triangle,  and  squares. 

The  triangular  cap  of  the  breast. 

The  cervico-thoracic  cravat. 

The  cervico-dorso-sternal  cravat. 

The  sacro-pubic  triangle. 

The  intercrural  cravat. 

The  cruro-pelvic  triangle. 


176 


SPECIAL,  OE  REGIONAL  BANDAGING. 


The  cruro-pelvic  cravat. 

The  sac ro-bi-c rural  cravats. 

The  sacro-lumbar  triangle. 

The  coxo-pelvic  triangle. 

RIGAL’S  BANDAGES  FOR  THE  NECK  AND  TRUNK. 
The  cervico-axillary  cravat. 

The  lateral  thoracic  bandage. 

The  sternal  triangle. 

The  dorsal  triangle. 

The  thoracico-abdominal  bandage. 

The  girdle. 


A.  Simple  Bandages. 

§ 1.  Circular  Bandages. 

Circular  Bandage  of  the  Neck.  Composition. — A roller  a yard 
and  a quarter  long  and  an  inch  and  a half  or  two  inches  wide. 

Application. — Confine  the  initial  extremity  upon  the  neck  by  a cir- 
cular turn,  and  finish  the  bandage  by  exhausting  the  roller. 

Use. — An  extremely  simple  mode  of  keeping  dressings  upon  the 
neck.  Care  should  be  taken  not  to  constrict  the  neck  in  such  a man- 
ner as  to  interrupt  the  circulation  in  the  bloodvessels  of  that  part  or 
interfere  with  the  respiration. 

Circular  Bandage  of  the  Body.  Composition. — A piece  of  mus- 
lin of  more  than  sufficient  length  to  go  around  the  body,  and  from  a 
foot  to  a foot  and  a half  wide.  If  the  bandage  is  to  be  applied  to  the 
chest  (circular  bandage  of  the  chest)  place  the  body  of  the  piece  of 
muslin  upon  the  back  and  bring  its  ends  to  the  front,  then  overlap 
and  pin  them. 

On  the  contrary,  if  the  abdomen  is  to  be  bandaged,  place  the  middle 
portion  of  it  upon  the  loins  (circular  bandage  of  the  abdomen).  In 
order  to  prevent  these  bandages  slipping  up  or  down,  two  small  strips 
of  muslin  are  sometimes  attached  to  their  upper  and  lower  edges,  pass- 
ing over  the  shoulder  and  under  the  perineum. 

An  abdominal  bandage  may  be  prepared  which  will  retain  its  place 
without  the  aid  of  scapular  or  perineal  strips.  It  consists  of  a piece 
of  muslin  with  gores  made  in  its  lower  margin  and  fitting  over  the 
hips,  the  bandage  being  prevented  from  wrinkling  by  four  pieces  of 
very  flexible  whalebone  inserted  vertically  at  the  sides  and  front.  Its 
anterior  edges  are  perforated  with  eyelet  holes  to  receive  the  lacing 
cord. 

Other  more  complicated  abdominal  supporters  are  often  recom- 
mended, but  this  one  will  answer  every  purpose,  and  may  be  made  in 
a few  minutes  in  any  household. 

Use. — The  circular  bandage  of  the  chest  is  used  to  insure  immo- 
bility of  the  walls  of  the  chest  in  fractures  of  the  bones  composing  it. 
The  abdominal  bandage  serves  the  purpose  of  supporting  the  walls  of 
the  abdomen  in  pregnancy,  after  confinement,  and  the  operation  of 
paracentesis. 


OBLIQUE  BANDAGES.  — FIGURE  OF  8 BANDAGES.  177 


§ 2.  Oblique  Bandages. 

The  Oblique  Bandage  of  the  Neck  and  Axilla. — 1st  Variety. 

Composition. — A roller  bandage  six  yards  long  and  two  inches  wide. 

Application. — Place  the  initial  extremity  of  the  bandage  upon  the 
shoulder  of  the  healthy  side,  and  confine  it  by  a circular  turn  passing 
across  the  chest  under  the  axilla  and  across  the  back  to  the  point  of 
starting.  The  bandage  is  finished  when  the  roller  shall  have  been 
exhausted  by  these  turns. 

Use. — As  a retentive  bandage  for  the  axilla,  but  it  is  badly  adapted 
for  this  purpose,  for  the  reason  that  the  turns  under  the  arm  become 
corded,  and  they  are  apt  to  gall  a tender  surface. 

2(7  Variety  ; the  oblique  bandage  of  the  neck  and  axilla,  for  venesection 
at  the  external  jugular  vein. 

Composition. — 1st.  A bandelette  four  yards  long  by  two  inches 
wide.  2d.  A prismatically  graduated  compress  about  three  inches 
long  by  two  inches  broad  at  its  base. 

Application. — Place  the  compress  over  the  external  jugular  vein 
just  above  the  clavicle,  and  over  this  place  that  portion  of  the  body 
of  the  bandelette  about  two  feet  from  its  extremity,  the  shorter  end 
hanging  obliquely  across  the  chest;  carry  the  longer  one  over  the 
shoulder  corresponding  to  the  vein  from  which  blood  is  to  be  taken, 
across  the  back  to  the  opposite  axilla,  under  which  it  passes  to  cross 
the  compress  and  shoulder  to  return  again  to  the  axilla.  Now  draw 
the  two  extremities  of  the  bandage  moderately  tight,  until  the  external 
jugular  bulges  sufficiently  to  be  opened,  and  then  tie  them  together. 

Use. — Only  in  venesection  at  the  neck. 

§ 3.  Spiral  Bandages. 

Spiral  Bandage  of  the  Body — Spiral  Bandage  of  the  Tho- 
rax. Composition. — A roller  ten  yards  long  and  two  inches  wide. 

Application. — Let  a yard  and  a half  of  the  free  extremity  of  the 
bandage  hang  down  from  the  right  shoulder  in  front  of  the  abdomen, 
then  carry  the  roller  across  the  back  under  the  left  axilla,  in  front  of 
the  chest  so  as  to  make  a circular  turn  of  the  thorax,  and  continue  in 
this  manner  descending,  each  turn  overlapping  a third  or  half  of  its 
predecessor,  towards  the  abdomen,  until  the  bandage  is  exhausted ; 
pin  its  terminal  extremity.  The  free  portion  is  now  to  be  reflected 
over  the  left  shoulder,  and  fastened  behind  with  pins. 

Use. — To  retain  dressings  upon  the  chest,  and  to  make  compression 
in  fracture  of  the  ribs.  In  the  latter  case  suitable  compresses  are 
to  be  employed,  of  which  two  are  to  be  placed  upon  either  side  of  the 
line  of  fracture  if  the  fragments  form  a salient  angle,  and  at  the  ex- 
tremities of  the  rib  if  it  is  re-entrant. 

§ 4.  Figure  of  8 Bandages. 

The  Posterior  Figure  of  8 of  the  Head  and  Axillas.  Com- 
position.— A roller  ten  yards  long  and  two  and  a half  inches  wide. 

_ Application. — Confine  the  initial  extremity  of  the  bandage  by  two 
circular  turns  at  any  point  of  the  circumference  of  the  head,  which  is 


178 


SPECIAL,  OR  REGIONAL  BANDAGING. 


drawn  backwards  as  far  as  desired;  when  the  roller  comes  to  the 
mastoid  process  of  the  left  side,  conduct  it  obliquely  across  the  neck 
and  right  scapula,  and  under  the  corresponding  axilla,  in  front  of  which 
you  must  ascend  to  the  point  of  departure ; from  whence  the  roller 
passes  around  the  forehead  to  the  mastoid  process  of  the  opposite  side, 
across  the  neck  to  the  left  axilla,  under  and  in  front  of  this  to  return 
to  the  neighborhood  of  the  right  ear,  when  the  head  is  to  be  surrounded 
by  a circular  turn  to  confine  the  first  two  oblique  turns.  Repeat  this 
course  again,  and  terminate  the  bandage  by  a circular  turn  around  the 
forehead. 

Use. — This  is  called  the  anterior  dividing  bandage,  and  is  used  to 
retain  the  head  in  a position  of  more  or  less  forced  extension  in  burns 
of  the  front  of  the  neck,  when  we  fear  distortion  from  excessive  con- 
traction of  the  cicatrix  drawing  the  head  forward.  The  bandage  is 
easily  deranged,  and  not  so  advantageous  for  this  purpose  as  others, 
to  be  described  further  on. 

It  should  be  mentioned  here,  that  in  all  of  those  bandages  which 
have  their  turns  passing  under  the  axilla,  the  sharp  margins  of  the 
latter,  formed  by  the  projection  of  the  pectoralis  major  and  the  latissi- 
mus  dorsi,  should  be  protected  by  suitable  compresses. 

The  Anterior  Figure  of  8 of  the  Head  and  Axillas. — This 
bandage  is  applied  in  the  same  manner  as  the  preceding,  only  re- 
versing it ; the  crosses,  which  are  upon  the  back  of  the  neck  in  the 
former,  are  in  front  in  the  latter. 

Use. — The  posterior  dividing  bandage  is  used  for  similar  purposes 
as  the  preceding,  when  the  injury  is  situated  upon  the  nape  of  the 
neck,  but  it  is  exceedingly  annoying  to  the  patient  by  the  crossings  of 
its  turns  upon  his  face,  at  the  same  time  being  less  effective  than  other 
dividing  bandages  to  be  mentioned  presently. 

The  Figure  of  8 of  the  Head  and  Axilla.  Composition. — A 
roller  seven  yards  long  by  an  inch  and  a half  wide. 

Application.- — Incline  the  head  at  the  desired  angle  upon  one  or  the 
other  side,  and  confine  the  initial  extremity  of  the  bandage  upon  the 
head  by  two  circular  turns ; then  pass  from  the  occiput  in  front  of  the 
shoulder  to  which  the  head  leans,  under  the  axilla,  up  over  its  poste- 
rior surface,  to  a point  just  above  the  nearest  eyebrow ; make  a reverse 
here,  in  order  to  pass  horizontally  around  to  the  nape  of  the  neck, 
thence  conduct  the  roller  in  front  of  and  under  the  axilla  to  the  fore- 
head, where  another  reverse  is  made  over  the  previous  one ; repeat 
these  turns  three  or  four  times,  and  terminate  the  bandage  by  circular 
turns  around  the  upper  part  of  the  arm.  Secure  the  reverses  with 
pins. 

Use. — To  bind  the  head  to  one  side  in  order  to  counteract  the  con- 
traction of  a cicatrix  upon  the  opposite  side  of  the  neck,  acting  thus 
as  a right  or  left  dividing  bandage  of  the  neck,  according  as  the  head 
is  drawn  to  the  left  or  right  side ; also  as  a uniting  bandage  for  the 
side  of  the  neck  to  which  the  head  is  inclined. 

The  Figure  of  8 of  the  Neck  and  Axilla.  Composition. — A 
roller  five  yards  long  and  two  inches  wide. 

Application. — Place  the  initial  end  of  the  bandage  upon  the  neck 


SPICA  OF  SHOULDER  AND  OPPOSITE  AXILLA,  179 

and  secure  it  by  two  circular  turns,  and  then,  if  the  object  is  to  cover 
in  the  right  axilla,  conduct  the  bandage  in  front  of  the  neck,  from  left 
to  right,  over  the  right  shoulder,  to  the  posterior  part  of  the  axilla, 
under  which  it  passes  to  ascend  in  front  of  the  same  shoulder  to  the 
nape  of  the  neck ; from  this  point  pass  around  the  neck  and  go  over 
the  same  course  three  times,  and  terminate  by  two  circular  turns 
around  the  upper  part  of  the  arm.  When  the  bandage  is  applied 
upon  the  left  side,  the  roller  must  pass  from  right  to  left.  It  may  also 
be  executed  with  a double-headed  roller,  in  which  case  the  body  is 
placed  under  the  axilla,  one  of  the  cylinders  is  conducted  in  front  and 
the  other  behind  the  shoulder  to  its  top,  where  a cross  is  made ; then 
the  former  passes  behind  the  neck  and  the  latter  in  front  of  it,  to  meet 
each  other  in  opposite  directions  upon  its  opposite  side.  The  rollers 
are  to  be  again  crossed  over  the  shoulder,  conducted  beneath  the 
axilla,  and  the  same  process  repeated  three  or  four  times. 

Use. — To  support  dressings  upon  the  shoulder  and  in  the  axilla. 
The  bandage  is  not  very  firm,  and  its  turns  cord  in  the  axilla,  and 
therefore  it  is  unsuitable  as  a retentive  means  of  topical  applications 
in  this  region. 

The  Spica  or  Figure  of  8 of  the  Shoulder  and  Opposite  Axilla. 
(Fig.  119.)  Composition. — A roller 

eight  yards  long  and  two  inches  wide. 

Application. — Confine  the  initial  ex- 
tremity to  the  upper  part  of  the  arm 
by  two  circular  turns,  and  when  the 
roller  arrives  at  the  posterior  margin 
of  the  axilla,  conduct  it  behind  the 
shoulder,  over  the  root  of  the  neck, 
across  the  front  of  the  chest  to  pass 
under  the  opposite  axilla,  and  oblique- 
ly across  the  back  to  the  top  of  the 
shoulder  again,  where  it  crosses  the 
previous  turn.  From  this  point  the 
cylinder  goes  under  the  axilla,  and 
over  the  same  course  as  before,  until 
five  or  six  turns  are  made,  or  as  many 
as  will  cover  the  shoulder  from  the 
root  of  the  neck  to  the  point  of  the 
acromion.  In  this  manner  one  cross 
follows  another  from  above  down- 
wards, when  the  spica  is  said  to  be 
descending  ; when  they  proceed  in  the 
reverse  direction,  the  spica  is  said  to 
be  ascending ; the  former  making  a firmer  and  neater  spica.  The 
terminal  extremity  of  the  bandage  may  be  fixed  with  a pin  in  front 
or  behind,  or  secured  in  the  manner  shown  in  the  figure.  It  may  also 
be  executed  with  a double-headed  roller,  by  placing  its  body  under 
the  axilla,  crossing  the  two  cylinders  above  the  corresponding  shoulder, 
and  conducting  them  around  the  chest  in  opposite  directions  to  the 
axilla  of  the  opposite  side,  where  they  pass  each  other  to  be  brought 


Fig.  119. 


The  spica  of  the  shoulder. 


180 


SPECIAL,  OR  REGIONAL  BANDAGING. 


back  to  and  crossed  over  the  injured  shoulder,  and  then  passed  under 
the  corresponding  axilla.  Eepeat  these  turns  until  the  bandage  is 
exhausted. 

Use. — To  retain  dressings  or  apparatus  upon  the  shoulder,  clavicle, 
and  scapular  region,  as  well  as  to  make  pressure  upon  the  former. 

The  Anterior  Figure  of  8 of  the  Shoulders.  Composition.— 
A roller  five  yards  long  by  two  inches  wide. 

Application. — Direct  an  'assistant  to  draw  the  shoulders  strongly 
forward,  and  to  retain  them  in  this  position  during  the  application  of 
the  bandage.  Confine  the  initial  extremity  of  the  bandage  to  the 
upper  part  of  the  right  arm,  passing  from  before  backwards,  ascend 

behind  the  right  shoulder  and 
cross  over  it  and  the  front  of 
the  chest  obliquely  to  the  left 
axilla,  pass  up  the  posterior 
surface  of  the  shoulder  to  its 
top,  when  the  roller  takes  a 
course  obliquely  across  the 
chest  to  the  right  axilla,  the 
two  turns  making  a figure  X 
over  the  sternum.  Eepeat 
these  turns  in  this  manner 
three  or  four  times  and  pin 
the  terminal  end  of  the  band- 
age to  them  either  in  front  or 
behind. 

Use. — To  prevent  the  forma- 
tion of  vicious  cicatrices  upon 
the  back  of  the  shoulder;  to  ap- 
proximate the  lips  of  wounds 
upon  the  anterior  and  upper 
parts  of  the  chest;  in  fracture 
of  the  upper  part  of  the  ster- 
num ; and  to  maintain  the 
reduction  of  the  inner  extremity  of  the  clavicle  dislocated  forwards. 

The  Posterior  Figure  of  8 of  the  Shoulders.  Composition. — 
A roller  five  yards  long  by  two  inches  wide. 

Application— T\\q  patient  being  seated  upon  a chair,  the  shoulders 
are  well  drawn  back.  Confine  the  initial  extremity  of  the  bandage  to 
the  upper  part  of  the  right  arm,  passing  from  behind  forwards  in  the 
axilla,  ascend  in  front  of  the  right  shoulder  to  the  root  of  the  neck, 
then  cross  the  back  of  the  chest  obliquely  to  the  left  axilla  under  it 
and  in  front  of  the  left  shoulder,  over  its  top,  and  thence  diagonally 
across  the  back,  the  turns  crossing  each  other,  to  the  right  axilla. 
Eepeat  this  course  three  times  and  terminate  the  bandage  by  pinning 
the  terminal  end  behind. 

The  Crossed  Bandage  of  the  Chest.  Composition. — A roller 
eight  yards  long  and  two  inches  wide. 

Application. — Place  the  initial  extremity  of  the  bandage  under  the 
right  axilla  and  conduct  the  roller  obliquely  upwards  across  the  chest 


Fiar.  120. 


THE  CROSSED  BANDAGE  OF  BOTH  BREASTS. 


181 


to  the  top  of  the  left  shoulder;  pass  behind  this,  and  beneath  the 
axilla  up  in  front  of  the  chest  to  the  root  of  the  neck ; then  go  ob- 
liquely across  the  back  of  the  thorax  to  the  right  axilla ; under  this 
to  the  front,  and  upwards  to  the  right  side  of  the  neck.  From  this 
point  the  roller  takes  its  course  obliquely  downwards  across  the  back 
of  the  chest  to  the  left  axilla,  under  which  it  passes  to  the  front  to 
cross  the  chest  to  the  right  shoulder,  behind  which  it  passes,  and  under 
the  right  axilla ; thence  upwards  to  the  top  of  the  left  shoulder  behind 
which  the  cylinder  courses  under  the  axilla  to  the  front,  and  upwards 
to  the  root  of  the  neck,  around  the  posterior  surface  of  this  part  to  the 
right  shoulder  and  axilla,  under  which  it  passes  to  gain  the  top  of  the 
same  shoulder,  and  to  cross  the  chest  obliquely  to  the  left  axilla ; from 
this  point  the  bandage  is  completed  by  three  or  four  circular  turns 
around  the  lower  portion  of  the  chest. 

A firmer  quadriga  may  be  made  with  a double-headed  roller 
wound  in  two  unequal  cylinders.  Place  its  body  under  the  right 
axilla,  conduct  the  two  cylinders  to  the  top  of  the  right  shoulder, 
where  they  are  crossed,  and  continued  to  the  left  axilla,  one  in  front 
the  other  behind  the  chest,  under  which  they  are  again  crossed,  and 
carried  to  the  top  of  the  left  shoulder  to  be  crossed  and  finally  brought 
to  the  right  axilla.  Repeat  this  course  two  or  three  times,  and  termi- 
nate the  bandage  as  in  the  former  instance. 

Use. — As  a retentive  bandage  in  fracture  of  the  ribs,  upper  part  of 
the  sternum,  and  dorsal  vertebrae.  It  is  rarely  ever  used,  however, 
its  place  having  been  usurped  by  the  spiral  or  circular  bandage  of  the 
chest,  and  by  long,  broad  strips  of  adhesive  plaster  laid  over  the  chest 
circularly. 

The  Crossed  Bandage  of  One  Breast.  Composition. — A roller 
eight  yards  long  by  two  inches  wide. 

Application. — Confine  the  initial  extremity  of  the  roller  under  the 
diseased  mamma,  the  left,  for  instance,  by  two  circular  turns,  passing 
from  left  to  right ; at  the  end  of  the  third  turn  direct  the  roller  ob- 
liquely between  the  two  breasts  to  the  middle  of  the  top  of  the  right 
shoulder,  descend  across  the  back  to  the  left  side,  and  make  a circular 
turn  of  the  chest  to  hold  the  oblique  one,  then  ascend  to  the  right 
shoulder  as  before.  Make  a sufficient  number  of  turns  in  this  manner 
to  cover  in  and  support  the  mamma,  and  terminate  the  bandage  by  a 
circular  turn  around  the  chest  above  or  below  that  organ  according 
to  the  circumstances  of  the  case. 

Use. — -To  support  and  retain  topical  applications  to  the  mamma,  and 
at  the  same  time  make  some  degree  of  compression. 

This  bandage  may  be  advantageously  supplanted  by  the  single  sling 
of  the  breast,  to  be  described  hereafter,  and  especially  when  it  is  neces- 
sary to  renew  the  dressings  frequently. 

The  Crossed  Bandage  of  Both  Breasts.  Composition. — A roller 
bandage  twelve  yards  long  by  two  inches  wide. 

Application. — Confine  the  initial  extremity  of  the  roller  upon  the 
lower  part  of  the  chest  by  three  circular  turns  passing  from  right  to 
left ; when  the  roller  in  the  third  turn  arrives  at  the  right  side  conduct 
it  obliquely  upwards  between  the  breasts  to  the  middle  of  the  top  of 


182  SPECIAL,  OR  REGIONAL  BANDAGING. 

the  left  shoulder,  thence  down  the  hack  to  the  point  of  departure  at  the 
right  side,  then  continue  it  transversely  around  the  thorax  to  the  left 
side,  obliquely  upwards  over  the  back  to  the  right  shoulder;  down  in 
front  of  the  chest  under  the  left  mamma,  transversely  across  the  body, 
around  the  right  side  and  upwards  again  between  the  breasts  to  the 
left  shoulder ; cross  the  back  to  the  right  side,  and  make  a horizontal 
turn  under  the  chest  to  the  right  shoulder,  descend  under  the  left  mam- 
ma and  transversely  around  the  posterior  surface  to  the  right  side.  In 
this  manner  make  in  all  four  or  five  crosses  upon  the  sternum,  or  un- 
til both  breasts  are  covered  in,  and  terminate  the  bandage  by  circular 
turns  around  the  body. 

A double-headed  roller  of  the  same  length  as  the  preceding,  and 
wound  in  two  unequal  cylinders,  may  also  be  employed  in  making  the 
double  cross  of  both  breasts. 

Place  the  body  of  the  roller  upon  the  middle  of  the  lower  and  posterior 
part  of  the  thorax,  bring  the  two  cylinders  forward  and  cross  them  be- 
tween the  two  mammae,  when  one  of  them  is  to  be  carried  over  the  right 
shoulder  and  the  other  over  the  left,  and  crossed  on  the  back ; repeat  this 
course  a second  time ; then,  holding  one  of  the  cylinders  at  the  back, 
conduct  the  longer  one  around  the  chest  circularly  to  confine  the  two 
oblique  turns.  Bring  both  of  the  cylinders  forward  again,  one  pass- 
ing under  each  breast.  Cross  them  over  the  sternum,  and  conduct 
them  one  over  either  shoulder,  when  another  circular  turn  is  to  be 
made  as  before.  Alternate  these  oblique  and  circular  turns  until  the 
bandage  is  exhausted,  and  secure  the  terminal  end  with  pins. 

Use. — Employed  in  the  similar  cases  as  the  crossed  bandage  of  one 
breast,  when  both  mammae  are  diseased. 

The  Crossed  Bandage  of  the  Groin  (Spica).  Composition. — A 
roller  seven  yards  long  and  two  inches  wide. 

Application. — Place  the  initial  extremity  of  the  bandage  upon  the 
abdomen,  just  above  the  umbilicus,  and  confine  it  by  two  or  three 
circular  turns,  passing  from  left  to  right  if  the  right  groin  is  to  be 
covered  in,  and  the  reverse  if  the  left.  When  the  roller  arrives  at 
the  right  flank,  carry  it  obliquely  across  the  upper  part  of  the  groin 
to  the  perineum,  going  between  the  right  thigh  and  scrotum:  then 
around  the  gluteal  muscles  to  the  point  just  above  the  right  superior 
spinous  process,  where  the  roller  is  conducted  across  the  abdomen  to 
the  left  side,  and  around  the  loins  to  the  right  side  again,  when  the 
same  process  is  gone  over  again  seven  or  eight  times,  or  until  the 
groin  is  covered  in;  each  turn  covering  half  of  its  predecessor  and 
placed  below  it;  terminate  the  bandage  by  circular  turns  around  the 
abdomen.  Made  in  this  manner,  the  spica  is  said  to  be  “ descending;" 
and  on  the  contrary,  when  the  turns  overlap  each  other  from  below 
upwards,  it  is  “ ascending.”  A double-headed  roller  may  also  be  used 
by  placing  its  body  upon  the  loins,  conducting  the  two  cylinders  for- 
wards, one  around  either  side,  crossing  them  over  the  groin,  and 
afterwards  behind  the  upper  part  of  the  thigh,  when  they  are  brought 
forwards  again  and  crossed.  Continue  this  process  until  the  bandage 
is  exhausted. 

Use. — To  sustain  dressings  upon  the  groin,  and  also  to  make  pres- 


COMPOUND  BANDAGES. 


183 


sure  in  cases  of  abscess,  sinus,  and  hernial  protrusions,  the  proper 
compresses  having  been  previously  applied  over  the  parts. 

The  Double  Spica,  or  Crossed  Bandage  op  Both  Groins. 
Composition. — A roller  twelve  yards  long  and  two  inches  wide. 

Application. — Place  the  initial  extremity  in  the  same  position  as 
for  the  single  spica,  and 'retain  it  by  three  circular  turns  around  the 
abdomen,  passing  from  right  to  left.  When  the  roller  comes  to  the 
right  side,  conduct  it  obliquely  across  the  abdomen  just  above  the 
penis  to  the  outer  side  of  the  left  thigh  below  the  trochanter;  pass 
over  the  back  of  the  limb  to  its  inner  side,  and  ascend  upwards 
towards  the  left  anterior  spinous  process,  crossing  the  previous  turn 
below  the  groin.  From  this  point,  carry  the  cylinders  to  the  corre- 
sponding process  upon  the  right  side,  across  the  loins,  down  in  front 
of  the  right  groin,  around  the  upper  part  of  the  right  thigh,  and  in 
front  to  cross  the  previous  turn,  and  ascend  to  the  left  flank  around 
the  back  to  the  right  side,  the  point  at  which  the  first  oblique  turn 
began.  Go  over  this  course  three  or  four  times,  making  an  ascending 
spica,  and  terminate  by  circular  turns  around  the  abdomen. 

The  same  bandage  may  be  executed  with  a double-headed  roller : 
place  its  body  upon  the  loins  and  make  two  circular  turns  around  the 
abdomen,  then  bring  the  cylinders  forwards,  cross  them  over  the 
pubis,  conducting  one  of  them  around  the  outer  surface  of  the  right 
thigh  and  the  other  around  the  left,  to  the  front,  passing  between  the 
scrotum  and  thighs;  then  cross  the  previous  turns  over  the  groins, 
when  the  cylinders  should  be  led  to  the  point  of  starting  upon  the 
loins.  The  same  manoeuvre  is  to  be  repeated  as  often  as  necessary  to 
cover  both  groins. 

Use. — In  similar  cases  as  the  single  spica,  when  the  disease  is 
seated  upon  both  groins. 

B.  Compound  Bandages. 

§ 1.  The  Double  T of  the  Body. 

The  Double  T of  the  Chest.  Composition. — A piece  of  muslin 
the  depth  of  the  chest,  and  of  sufficient  length  to  entirely  surround 
the  body  and  overlap  three  or  four  inches,  and  two  pieces  of  muslin, 
each  two  feet  long  and  two  inches  wide. 

Application. — Place  the  body  of  the  bandage  upon  the  back  of  the 
thorax,  bring  its  two  ends  forwards,  overlap  them,  and  pin.  To  pre- 
vent the  bandage  slipping  down,  the  two  bandelettes,  passing  one  over 
each  shoulder,  are  pinned  to  its  superior  margin. 

The  Double  T of  the  Abdomen.  Composition. — The  same  as  the 
preceding  bandage. 

Application. — The  body  of  the  bandage  is  placed  over  the  loins,  and 
its  ends  brought  forwards  over  the  abdomen,  and  pinned.  The  two 
straps  are  conducted  beneath  the  perineum  and  fastened  to  the  lower 
margin  of  the  bandage. 

Use. — The  double  T of  the  chest  is  used  to  retain  dressings  upon 
the  upper  portion  of  the  body,  and  to  restrain  the  movements  of  the 
chest  in  fracture  of  the  ribs. 


184 


SPECIAL  OR  REGIONAL  BANDAGING. 


The  double  T of  the  abdomen  is  employed  to  maintain  topical  reme- 
dies upon  the  lower  portion  of  the  body,  and  also  to  make  compres- 
sion, as  after  the  operation  of  paracentesis  abdominis  and  accouchement, 
and  to  prevent  the  displacement  of^the  bowels  in  eventration. 

The  Anterior  Double  T of  the  Head  and  Chest.  Composition. 
— 1st.  A double  T bandage  of  the  chest.  2d.  Four  bandelettes,  one 
four  yards  long  and  two  inches  wide,  to  the  superior  border  of  which 
is  sewed  a second  bandelette  two  feet  long  and  of  the  same  width,  and 
to  its  lower  border  the  ends  of  the  other  two  bandelettes,  each  a foof 
and  a half  long  and  one  inch  wide,  one  fifteen  and  the  other  twenty 
inches  from  the  initial  extremity;  the  superior  bandelette  being  be- 
tween them. 

Application. — First  fix  the  bandage  to  the  thorax,  then  place  the 
initial  extremity  of  the  long  arm  of  the  bandelette  over  the  right  eye- 
brow and  confine  it  by  a circular  turn,  bringing  the  superior  bande- 
lette over  the  forehead  in  the  median  line.  The  latter  is  now  to  be 
conducted  to  the  occiput,  looped  around  the  circular  turn,  and  brought 
forward  again  and  pinned  over  the  top  of  the  head,  when  other  circu- 
lar turns  are  made  until  the  band  is  exhausted.  Xow  flex  the  head 
to  the  required  angle,  and  hold  it  in  that  position  by  pinning  the  two 
strips  hanging  down  from  either  side  of  the  head  upon  the  chest  band- 
age. 

Use. — Used  as  a uniting  bandage  of  wounds  of  the  anterior  portion 
of  the  neck,  and  as  a dividing  bandage  in  burns  upon  the  posterior 
surface  of  the  same  part. 

The  Posterior  Double  T of  the  Head  and  Chest. — This  band- 
age is  applied  in  the  same  manner  except  that  the  two  vertical  pieces 
of  muslin  should  descend  the  back. 

Use. — To  draw  the  head  backwards,  and  is  used  under  exactly  the 
reverse  circumstances  of  the  anterior  double  T. 

The  Double  T of  the  Pelvis.  Composition. — An  oblong  piece  of 
muslin,  folded  upon  itself,  about  four  inches  wide,  and  sufficiently 
long  to  more  than  complete  the  circuit  of  the  pelvis  by  three  or  four 
inches.  To  the  middle  of  its  inferior  margin  sew  two  strips  of  muslin, 
one  inch  wide  and  a yard  long,  at  a distance  of  one  inch  and  a half 
apart. 

Application. — Place  the  body  of  the  bandage  over  the  sacrum  so 
that  the  two  strips  may  hang  down  behind  opposite  the  scrotum,  bring 
its  lateral  ends  forward,  overlap,  and  pin  them  securely  ; then  conduct 
the  two  bandelettes  between  the  legs,  one  upon  each  side  of  the  scro- 
tum, and  pin  them  to  the  bandage  in  front.  Where  only  one  strip  of 
muslin  is  employed,  the  single  T is  formed. 

Use. — To  maintain  dressings  upon  the  sacrum,  anus,  perineum,  and 
vulva. 

The  T Bandage  of  the  Groin  (Fig.  121).  Composition. — A triangu- 
lar piece  of  muslin  of  sufficient  size  to  cover  in  the  groin  and  to  extend 
to  the  middle  of  the  thigh.  To  one  angle  of  its  base  sew  the  end  of  a strip 
of  muslin  two  and  a half  yards  long  and  an  inch  and  a half  wide;  to  the 
other  a strip  of  the  same  width  and  four  yards  long.  To  the  apex 


SLING  BANDAGES. 


185 


of  the  triangle  is  attached  the  middle 
of  a third  strip,  a yard  long  and  of 
the  same  width  as  the  preceding. 

Application. — Place  the  base  of  the 
triangle  just  above  Poupart’s  liga- 
ment with  that  angle  of  the  base  to 
which  the  long  bandelette  is  attached 
looking  towards  the  healthy  side,  for 
instance,  the  left ; then  carry  the 
band  of  the  outer  angle  around  the 
left  hip,  across  the  small  of  the  back, 
and  in  front  of  the  lower  portion  of 
the  abdomen  to  the  point  of  depar- 
ture; let  it  be  held  there  until  the 
band  connected  to  the  inner  angle 
shall  have  been  carried  around  the 
right  hip  obliquely  across  the  sacrum 
to  the  outer  part  of  the  left  thigh, 
around  which  it  passes  in  front  upon 
the  triangle  to  the  right  flank,  and 
across  the  back  to  the  left  flank, 
when  the  two  ends  are  to  be  tied  together.  The  apex  of  the  triangle 
is  fixed  by  a circular  turn  around  the  middle  of  the  thigh. 

Use. — To  hold  dressings  upon  the  groin,  but  it  is  inefficient  when 
the  patient  moves  around. 

§ 2.  The  Crossed  Banda  ye  of  the  Trunk. 

This  bandage  is  very  similar  to  the  T bandage  of  the  trunk,  and  is 
composed  of  a broad  piece  of  muslin  to  go  around  the  chest  and  over- 
lap three  inches,  with  two  straps  attached  to  its  superior  border  which 
pass  over  the  shoulders,  and  two  to  its  inferior  margin  passing  under 
the  perineum.  It  may  be  similarly  applied  to  the  abdomen. 

Use. — The  cross  bandage  of  the  trunk  is  used  under  similar  circum- 
stances as  the  double  T bandages  of  the  same  part. 

§ 3.  Sling  Bandages. 

The  Sling  Bandage  of  the  Shoulder.  Composition. — A piece 
of  muslin  eight  or  ten  inches  wide  and  two  yards  and  half  long,  split 
from  each  end  into  two  tails. 

Application. — Place  the  body  of  the  bandage  over  the  shoulder,  con- 
duct its  superior  tails,  one  in  front  and  the  other  behind  the  chest,  to 
the  opposite  axilla,  cross  them  here,  and  bring  them  back  to  the 
shoulder  and  tie  them ; the  inferior  ones  are  exhausted  by  circular 
turns  around  the  upper  part  of  the  arm. 

Use. — This  bandage  is  used  to  support  dressings  upon  the  shoulder  ; 
but  it  is  not  very  firm. 

The  Sling  Bandage  of  the  Breast.  Composition. — A piece  of 
muslin  eight  or  twelve  inches  square,  having  sewed  to  one  of  its  sides 
a muslin  strip  three  yards  long  and  two  inches  wide,  and  to  each  of  its 
opposite  angles  a narrow  strip  an  inch  and  a half  wide  and  a yard  long. 


Fig.  121. 


The  T bandage  of  the  groin. 


186 


SPECIAL,  OR  REGIONAL  BANDAGING. 


Application. — Place  the  square  piece  of  muslin  over  the  breast,  with 
the  broad  band  horizontal,  the  two  ends  of  which  latter  are  now  to  be 
carried  around  the  chest  beneath  the  mammae,  crossed  upon  the  back, 
brought  forward  and  pinned  in  front.  The  two  narrow  strips  are 
passed  around  the  neck,  one  upon  either  side,  to  its  back  part  over 
which  they  are  tied  in  a bow  knot. 

Use. — To  support  the  breast,  and  to  sustain  poultices  or  other  dress- 
ings in  place. 

The  Sling  Bandage  of  the  Hip.  Composition. — A piece  of  mus- 
lin two  yards  and  a half  long  and  eight  or  ten  inches  wide,  split  at 
each  end  in  two  parts. 

Application. — Place  the  body  of  the  bandage  over  the  hip,  conduct 
its  superior  extremities  around  the  loins,  cross  them  there,  and  finally 
tie  them  on  the  same  side  on  which  the  bandage  is.  The  two  extremi- 
ties are  to  be  fastened  by  a knot  around  the  upper  part  of  the  thigh. 

Use. — To  retain  dressings  over  the  hip. 


§ 4.  Suspensory  Bandages. 

The  Suspensory  Bandage  of  the  Breast.  Composition.  — A 
piece  of  muslin  about  eight  inches  wide  and  nine  inches  long ; fold  it 
upon  itself  lengthwise  and  remove  with  the  scissors  the  angles  adjoin- 
ing the  folded  border,  and  sew  the  edges  thus  made  together.  To  the 
two  upper  angles  attach  two  bandelettes  one  inch  wide  and  a foot  and 
a half  long,  and  to  the  inferior  angles  two  or  more  of  similar  width 
but  a yard  and  a quarter  long. 

Application. — Place  this  sort  of  cap-like  piece  of  muslin  over  the 
diseased  mamma,  carry  the  superior  bandelettes  around  the  neck,  and 
tie  them  behind  it,  and  the  inferior  ones  around  the  chest ; cross  them 
over  the  posterior  surface  of  the  chest,  and  finally  bring  the  ends 
forward  again  to  be  tied  or  pinned  in  front. 

Use. — To  support  the  mamma  when  large  and  pendulous,  and  to 
retain  topical  dressings  upon  the  part. 

The  Suspensory  Bandage  of  the  Scrotum.  Composition. — A piece 
of  muslin  (Fig.  122),  whose  size  will  vary  according  to  the  volume  of  the 

testicles,  must  be  taken ; for  or- 
Fig.  123.  dinary  use,  six  inches  wide  and 

eight  inches  long  will  answer; 
fold  it  in  the  direction  of  its 
length,  and  with  the  scissors, 
remove  the  angles  ( a d and  b a) 
in  the  direction  of  the  dotted 
lines,  sew  the  edges  together 
along  the  line  (a,  b),  and  also 
sew  to  the  angles  ( b ) the  ex- 
tremities of  two  pieces  of  mus- 
lin one  inch  wide  by  two  feet 
long,  each  having  a button-hole 
worked  in  the  free  end.  At- 
m . . , ..  tach  the  two  borders  (c,  d)  to 

Tlie  suspensory  bandage  of  the  scrotum.  ^ \ j j 


Fig.  122. 


MAYOR’S  BANDAGES  FOR  THE  TRUNK.  187 

the  middle  of  a muslin  strip  doubled  upon  itself  and  sewed  together 
to  make  a sort  of  belt,  an  inch  wide  and  two  yards  and  a half  long, 
with  a button  near  each  free  extremity. 

Application. — Introduce  the  scrotum,  covered  with  its  dressings, 
into  the  suspensory,  with  the  penis  projecting  out  of  the  aperture  in 
front,  carry  the  horizontal  bands  around 
the  pelvis,  cross  them  behind,  and  finally 
bring  them  to  the  front,  and  fasten  the 
extremities  over  the  pubis  with  a pin  or 
button.  The  two  other  strips  are  conducted 
behind,  around  the  upper  portion  of  the 
thigh,  one  upon  each  side,  and  are  buttoned 
over  the  groins,  as  seen  in  Fig.  123. 

A very  elegant  suspensory  is  supplied  by 
the  shops,  manufactured  by  weaving  together 
cotton  or  silk  threads,  either  alone  or  with 
caoutchouc  threads.  (Fig.  124.) 

Use. — -To  support  the  scrotum,  in  orchitis;  varicocele;  and  irredu- 
cible hernias. 


Fig.  124. 


Elastic  suspensory  bandage. 


§ 5.  Sheath  Bandages. 

The  Sheath  of  the  Penis.  Composition. — A sheath  of  muslin  large 
enough  to  hold  the  penis  is  made,  and  to  its  base  two  strips  of  muslin 
are  to  be  sewed  sufficiently  long  to  reach  around  the  body.  Cut  a 
small  hole  in  its  apex  to  permit  the  passage  of  the  urine. 

Application. — Place  the  necessary  dressings  upon  the  penis  and  slip 
the  sheath  over  them,  conduct  the  two  strips  around  the  pelvis  and 
knot  them  behind. 

Use. — To  sustain  the  penis  upon  the  abdomen  during  inflammatory 
affections  of  that  organ,  and  also  to  retain  dressings  upon  it. 

C.  Mayor’s  Bandages  for  the  Trunk. 

The  Cravat  of  the  Neck.  Composition. — A triangular  piece  of 
muslin  folded  in  a cravat. 

Application. — Place  the  body  of  the  cravat  upon  any  part  of  the 
neck,  cross  the  lateral  extremities  upon  the  opposite  side,  and  finally 
bring  them  back  and  knot  them  together.  Mayor  recommends  the 
insertion  of  a piece  of  stiff  paper  in  the  folds  of  the  triangle,  or  when 
suppuration  is  profuse,  light  wire  gauze,  to  prevent  the  cravat’s 
wrinkling. 

Use. — To  confine  dressings  upon  the  neck. 

The  Occipito-Thoracic  Triangle  (Occipito-Sternal).  Com- 
position.— Two  triangular  pieces  of  muslin,  a yard  and  a quarter  long 
by  eighteen  inches  from  the  middle  of  the  base  to  the  apex ; one  is  to 
be  folded  in  a cravat. 

Application. — Place  the  body  of  the  cravat  over  the  sternum  and 
tie  its  lateral  ends  behind  the  back.  The  base  of  the  triangle  is  now 
placed  over  the  occiput,  and  its  two  extremities  fastened  in  front  to 
the  sternal  cravat  after  the  head  has  been  flexed  to  the  necessary 


188 


SPECIAL  OR  REGIONAL  BANDAGING. 


extent ; the  apex  is  to  be  carried  over  and  pinned  upon  either  side  of 
the  bandage. 

Use. — As  a substitute  for  the  flexor  bandages  of  the  head  already- 
described. 

The  Fronto-Thoracic  Triangle  (Fronto-Sternal). — The  only 
difference  between  the  mode  of  applying  this  bandage  and  the  pre- 
ceding is  that  the  base  of  the  triangle  should  be  placed  upon  the  fore- 
head instead  of  the  occiput,  and  its  tails  tied  to  the  cravat  behind. 

Use. — As  a substitute  for  the  extensor  bandage  of  the  head  already 
mentioned. 

The  Parieto-Axillary  Triangle.  Composition. — A triangular 
piece  of  muslin  a yard  and  a quarter  long  and  eighteen  inches  from 
base  to  apex. 

Application. — Place  the  base  of  the  triangle  upon  the  parietal  emi- 
nence on  either  side,  carry  the  lateral  angles  under  the  opposite  axilla, 
where  they  are  to  be  tied,  or  else  to  a cravat,  which  has  been  prelimi- 
narily knotted  around  the  shoulder  of  that  side.  The  apex  may  be 
conducted  around  the  head  and  pinned  over  either  temple. 

Use. — To  bend  the  head  to  one  side  or  the  other,  and  to  replace  the 
figure  of  8 bandage  of  the  head  and  axilla. 

The  Thoracico-Scapular  Triangle.  Composition. — A triangular 
piece  of  muslin  a yard  and  a quarter  long  and  eighteen  inches  from 
base  to  apex.  > 

Application. — Place  the  base  of  the  triangle  beneath  the  part  to 
which  the  dressings  are  applied  either  upon  the  anterior  or  posterior 
aspect  of  the  chest,  conduct  its  extremities  to  the  opposite  side,  and 
tie  them.  The  apex  may  be  carried  over  the  right  or  left  shoulder, 
and  connected,  by  lengthening  it  if  necessary,  with  one  of  the  ex- 
tremities of  the  bandage. 

The  Simple  Bis-Axillary  Crayat  (Fig.  125).  Composition. — A 

piece  of  muslin  a yard  and 
a quarter  long  and  eigh- 
teen inches  deep,  folded  in 
a cravat. 

Application. — Place  the 
body  of  the  bandage  upon 
the  diseased  axilla  after  the 
dressings  have  been  ap- 
plied ; the  lateral  extremi- 
ties should  then  be  crossed 
over  the  shoulder  of  the 
same  side,  and  carried  one 
behind  and  the  other  in 
front  of  the  chest  to'  the 
opposite  axilla,  where  they 
are  to  be  tied. 

Use. — To  retain  dressings  upon  the  axilla  and  to  replace  the  reten- 
tive bandages  of  this  region. 

The  Compound  Bis-Axillary  Cravat.  Composition. — Two  cravats 
a yard  and  a quarter  long. 


Fig.  125. 


mayor’s  bandages  for  the  trunk. 


1S9 


Application. — Place  the  body  of  one  of  the  cravats  upon  one  of  the 
axillae,  and  tie  its  extremities  over  the  corresponding  shoulder.  The 
body  of  the  other  cravat  is  laid  over  the  other  axilla,  and  its  extremi- 
ties are  carried  one  over  the  front,  and  the  other  behind  the  chest, 
looped  around  the  first  cravat,  and  tied  in  front. 

• Use. — To  retain  dressings  upon  both  axillae. 

The  Simple  Dorso-bis- Axillary  Cravat.  Composition.— A cra- 
vat a yard  and  a half  long. 

Application.- — Place  the  body  of  the  cravat  between  the  shoulder- 
blades  in  an  oblique  direction  so  that  one  of  its  lateral  extremities 
may  pass  over  one  shoulder  and  the  other  under  the  axilla  of  the  op- 
posite side,  then  bring  the  former  under  the  axilla  and  the  latter  over 
the  shoulder,  and  tie  them  together  over  the  back. 

Use. — To  draw  both  shoulders  backwards,  thus  fulfilling  the  same 
indications  as  the  posterior  figure  of  8. 

The  Compound  Dorso-bis-Axillary  Cravat.  Composition. — Two 
cravats  a yard  long. 

Application. — Place  the  body  of  one  of  the  cravats  in  front  of  the 
left  shoulder,  and  knot  its  extremities  upon  its  opposite  side,  thus 
forming  a kind  of  loose  ring.  The  body  of  the  other  cravat  is  laid 
over  the  corresponding  part  of  the  right  shoulder,  and  its  extremities 
carried  behind;  the  superior  one  looping  around  the  cravat  upon  the 
opposite  side,  and  the  inferior  extremity  looping  around  the  superior, 
when  their  ends  are  to  be  tied  together. 

Use. — The  same  as  the  preceding. 

The  Cravat. — Triangular  and  oblong  pieces  of  muslin  may  also  be 
employed  to  retain  dressings  upon  the  chest  and  abdomen,  and  to  make 
compression  ; their  application  is  obvious. 

The  Triangular  Cap  for  the  Breast.  Composition. — A trian- 
gular piece  of  muslin  a yard  and  a quarter  long  and  eighteen  inches 
deep. 

Application. — Place  the  base  of  the  triangle  beneath  the  suffering 
organ,  carry  one  of  its  extremities  under  the  corresponding  axilla,  and 
the  other  over  the  opposite  shoulder,  and  tie  them  together  behind ; 
the  apex  is  conducted  over  the  shoulder  and  pinned  to  the  bandage 
behind. 

The  Cervico-Thoracic  Cravat. — A cravat  a yard  and  a quarter 
long,  with  its  base  placed  upon  the  nape  of  the  neck,  and  its  extremi- 
ties drawn  down  in  front  and  pinned  to  a body  bandage.  It  is  princi- 
pally employed  as  a scapulary. 

The  Cervico-dorso-sternal  Cravat.  Composition. — A triangle 
of  muslin  a yard  and  a quarter  long. and  eighteen  inches  deep. 

Application. — Place  its  base  upon  the  nape  of  the  neck  and  bring  its 
lateral  extremities  forward  to  be  pinned  to  a body  bandage,  while  its 
apex,  hanging  down  the  back,  is  fastened  to  the  bandage  behind. 

Use. — To  confine  dressings  upon  the  back. 

The  Sacro  Pubic  Triangle  (Posterior  Pelvic).  Composition. — 
A triangle  a yard  and  a quarter  long  and  eighteen  inches  deep. 

Application. — Place  the  base  of  the  triangle  upon  the  loins,  con- 
duct its  extremities  around  the  flanks,  and  tie  them  together  in  front 


190  SPECIAL,  OR  REGIONAL  BANDAGING. 

of  the  abdomen.  The  apex  is  now  to  be  brought  forward  under  the 
perineum  between  the  thighs,  and  pinned  to  the  extremities. 

Use. — To  retain  dressings  upon  the  posterior  surface  of  the  pelvis 
and  perineum. 

The  Intercrural  Cravat.  Composition. — Two  cravats,  each  a 

yard  long. 

Application. — Fasten  one  of  them  around  the  loins  with  pins,  the 
body  of  the  other  cravat  is  placed  over  the  perineum  and  its  extre- 
mities brought  upwards,  one  in  front  and  the  other  behind  the  pelvis, 
and  pinned  to  the  first  cravat. 

Use. — To  maintain  topical  dressings  upon  the  perineum,  anus,  and 
vulva,  and  intended  to  replace  the  double  T bandage  used  for  the  same 
purpose. 

The  Cruro-Pelvic  Triangle  ( Cruro-Inguinal ) (Fig.  126). 

Composition. — A triangle  a yard  and  a half 
from  one  extremity  to  the  other,  and  two  feet 
deep. 

Application. — Place  the  base  of  the  triangle 
obliquely  across  the  groin ; for  instance,  the 
right  one,  conduct  the  superior  extremity 
around  the  left  side,  across  the  loins  to  the 
right  groin,  where  it  is  pinned  to  the  band- 
age. The  inferior  end  should  be  carried  around 
the  upper  part  of  the  right  thigh  between  it 
and  the  scrotum,  to  a point  near  the  superior 
extremity,  and  fastened  with  a pin. 

Use. — To  keep  dressings  upon  the  groin, 
hip,  and  upper  part  of  the  thigh. 

The  Cruro-Pelvic  Cravat  (Inguinal). 
Composition. — A cravat  a yard  and  a half  long. 
Application.  — Place  the  body  obliquely 
upon  the  diseased  groin,  we  will  say  the  right ; then  conduct  its  upper 
extremity  behind  around  the  left  side  to  the  right  hip  and  its  inferior 
one  downwards  just  above  the  penis,  across  the  upper  part  of  the  thigh, 
between  it  and  the  scrotum  to  the  right  hip,  where  the  two  ends  are  to 
be  knotted  together. 

Use. — To  maintain  poultices  and  other  dressings  to  the  groin. 

The  Sacro-bi-Crural  Cravats.  Composition. — Two  cravats,  each 
a yard  and  a quarter  long. 

Application. — Knot  one  of  the  extremities  of  each  cravat  together; 
then  place  this  part  of  the  bandage  over  the  sacrum,  and  conduct  each 
cravat  around  its  corresponding  side  over  both  groins,  backwards  be- 
tween the  scrotum  and  thigh,  one  upon  either  side  and  around  the 
upper  parts  of  the  thighs ; the  extremity  of  the  right  cravat  should 
be  pinned  to  the  bandage  over  the  groin  of  the  left  side,  and  that  of 
the  left  cravat  over  the  right  groin. 

Use.— For  the  same  purposes  as  the  double  spica. 

The  Sacro-Lumbar  Triangle  (Suspensory)  (Fig.  127).  Compo- 
sition.— 1st.  A triangle  three-fourths  of  a yard  long  and  a foot  from  its 
base  to  its  apex.  2d.  A cravat  a yard  long. 


Fig.  126. 


rigal’s  bandages  for  the  trunk. 


191 


Application. — Surround  the  loins  with  the  cravat,  and  then  place 
the  base  of  the  triangle  upon  the  back  part  of  tire  scrotum ; conduct 
its  two  lateral  extremities  upwards,  and  form 
loops  around  the  cravat,  passing  from  before 
backwards,  and  bring  them  to  the  median 
line,  passing  outside  of  that  portion  of  the 
triangles  in  contact  with  the  scrotum,  when 
they  are  to  be  knotted  together.  The  apex  is 
now  drawn  upwards  over  the  scrotum  and 
penis,  slipped  under  the  knot,  and  the  cravat 
reflected  upon  itself,  and  pinned. 

Use. — This  is  used  when  a suspensory  band- 
age is  indicated. 

The  Coxo-Pelvic  Triangle.  Composi- 
j i [ion. — 1st.  A triangle  a yard  and  a quarter 
long  and  eighteen  inches  deep.  2d.  A cravat 
a yard  and  a half  long. 

Application. — Apply  the  cravat  around  the 
body  just  above  the  hips;  then  place  the  base 
of  the  triangle  on  the  upper  and  posterior  part  of  the  thigh ; conduct  its 
extremities  around  this,  cross  them  upon  the  opposite  side,  beneath 
the  perineum,  and  finally  bring  them  back  and  tie  them  together  over 
the  posterior  surface  of  the  thigh.  Now  draw  the  apex  of  the  triangle 
upwards,  loop  it  around  the  cravat,  and  fasten  it  with  a pin. 

Use. — To  retain  dressings  upon  the  gluteal  region. 

D.  Rigal’s  Bandages  for  the  Trunk. 

The  Cervico-Axillary  Cravat.  Composition. — A cravat  a yard 
long,  and  an  India-rubber  ring. 

Application. — Place  the  body  of  the  cravat  upon  the  diseased  axilla, 
and  pass  its  extremities  through  the  elastic  ring  over  the  opposite 
shoulder,  when  they  are  to  be  reflected  upon  themselves  and  tied 
together  upon  the  opposite  side  of  the  neck. 

Use. — Used  as  a retentive  dressing  for  the  axilla. 

The  Lateral  Thoracic  Bandage.  Composition. — A handkerchief 
folded  in  a triangle. 

Application. — Place  the  base  of  the  triangle  upon  either  the  right  or 
left  side,  over  the  false  ribs ; conduct  its  extremities  circularly  around 
the  body  to  a point  exactly  opposite,  and  pin  them  together.  Draw 
the  two  angles  of  the  apex,  one  in  front  and  the  other  behind  the  chest, 
to  the  opposite  shoulder,  over  which  they  are  tied. 

Use. — This  bandage  covers  in  two-thirds  of  the  chest,  front  and 
! back,  and  is  a ready  means  of  retaining  dressings  upon  extensive  burns 
of  that  region. 

The  Sternal  Triangle.  Composition. — 1.  A handkerchief  or 
'square  piece  of  muslin  folded  in  a triangle;  2.  An  elastic  thread. 

Application. — Place  the  base  of  the  triangle  over  the  epigastrium, 
and  carry  its  lateral  angles  around  the  body,  and  tie  them  upon  its 
posterior  surface ; then  raise  the  apex  of  the  triangle  to  the  root  of  the 


Fig.  127. 


192 


SPECIAL,  OR  REGIONAL  BANDAGING. 


neck,  separate  its  angles,  and  conduct  one  upon  either  side  of  it  to  the 
nape  of  the  neck,  where  they  are  to  be  knotted  together ; now  loop 
the  middle  of  the  elastic  thread  around  the  upper  knot,  conduct  the 
two  halves  vertically  to  the  lower  knot,  to  which  they  are  also  fastened 
with  a thread,  then  separate  them  that  they  may  pass  over  the  nates, 
under  the  perineum,  and  around  the  outer  surface  of  the  hips,  to  the 
posterior  portion  of  the  iliac  crest,  where  each  thread  loops  around  its 
own  portion;  they  are  finally  brought  forward  again,  one  upon  the 
right  the  other  upon  the  left  side,  and  fastened  to  the  lower  margin 
and  middle  of  the  base  of  the  triangle. 

Use. — Employed  for  retaining  dressings  upon  the  whole  anterior 
portion  of  the  chest. 

The  Dorsal  Triangle. — This  is  applied  in  the  same  manner,  only 
placing  the  triangle  upon  the  posterior  surface  of  the  chest. 

Use. — As  a retentive  bandage  for  the  posterior  surface  of  the  chest. 

The  Thoracico-Abdominal  Bandage.  Composition— A handker- 
chief folded  in  a triangle  with  the  two  angles  of  the  apes  truncated, 
and  four  elastic  threads. 

Application. — Place  the  base  of  the  triangle  transversely  across  the 
middle  portion  of  the  trunk  with  the  apex  hanging  downwards;  con- 
duct its  lateral  angles  around  the  body  and  knot  them  together  be- 
hind ; now  raise  the  anterior  angle  to  the  top  of  the  sternum,  and  sup- 
port it  in  that  position  by  an  elastic  thread  passing  around  the  nape 
of  the  neck  and  fastened  to  its  two  corners.  To  each  corner  of  the 
inferior  angles  elastic  threads  are  attached,  which  pass  backwards  be- 
tween the  thighs  around  the  upper  and  outer  surface  of  the  hip,  one 
upon  each  side,  to  be  fastened  to  the  bandage  in  front  just  above  the 
groin. 

To  prevent  the  elastic  ring  round  the  neck  working  up,  a cord  of 
the  same  material  connects  it  vertically  with  the  knot  upon  the  middle 
line  of  the  back. 

Use. — This  bandage  will  serve  very  well  to  retain  lint  or  other 
dressings  upon  burns  of  a large  extent  of  the  anterior  surface  of  the 
body. 

The  Girdle.  Composition. — A cravat  a yard  and  a quarter  long, 
and  an  elastic  ring. 

Application. — Place  the  body  of  the  cravat  upon  the  abdomen  and 
conduct  its  extremities  to  the  posterior  surface  of  the  body,  where 
they  are  passed  through  the  elastic  ring,  and  are  then  brought  forward 
again  and  pinned  to  the  body  of  the  cravat  over  the  loins. 

Use. — To  support  the  abdomen  when  pendulous. 


BANDAGES  OF  THE  UPPER  EXTREMITIES. 


193 


SECTION  III. 

BANDAGES  OF  THE  UPPER  EXTREMITIES. 

SIMPLE  BANDAGES. 

Circular  Bandages. 

The  circular  bandage  of  a finger. 

The  circular  bandage  of  the  forearm. 

The  circular  bandage  of  the  arm. 

Spiral  Bandages. 

The  spiral  bandage  of  a finger. 

The  spiral  bandage  of  all  the  fingers  (Gauntlet). 

The  spiral  bandage  of  the  hand  and  fingers. 

The  spiral  bandage  of  the  forearm. 

The  spiral  bandage  of  the  arm. 

The  spiral  bandage  of  the  whole  arm. 

Figure  of  8 Bandages. 

The  figure  of  8 bandage  of  the  thumb  and  wrist. 

The  posterior  figure  of  8 bandage  of  the  hand  and  wrist. 
The  anterior  figure  of  8 bandage  of  the  hand  and  wrist. 

The  figure  of  8 bandage  of  the  elbow. 

The  extensor  figure  of  8 bandage  of  the  hand  and  forearm. 
The  flexor  figure  of  8 bandage  of  the  hand  and  forearm. 
Recurrent  Bandages. 

The  recurrent  bandage  of  a stump  of  the  arm  and  forearm. 
The  recurrent  bandage  after  disarticulation  at  the  shoulder. 
Bandages. 

The  large  quadrilateral  scarf  of  the  arm  and  chest. 

The  oblique  quadrilateral  scarf  of  the  arm  and  chest. 

The  scarf  of  the  arm  and  neck. 

The  scarf  of  the  hand  and  forearm. 

COMPOUND  BANDAGES. 

T Bandages. 

The  simple  T bandage  of  the  hand. 

The  double  T bandage  of  the  hand. 

The  perforated  T bandage  of  the  hand. 

Sling  Bandages. 

The  sling  bandage  of  the  hand. 

The  anterior  sling  bandage  of  the  elbow. 

The  posterior  sling  bandage  of  the  elbow. 

Sheath  Bandages. 

The  sheath  bandage  of  the  fingers. 

Laced  and  Buckle  Bandages. 

The  laced  bandage  of  the  arm. 

The  laced  bandage  of  the  body  (strait  jacket). 

MAYOR’S  BANDAGES  OF  THE  UPPER  EXTREMITIES. 
Cravats,  triangles,  and  squares. 

The  carpo-digito  dorsal  triangle. 

The  interdigital  triangle. 

The  palmo-digito-brachial  triangle. 

The  carpo-olecranon  cravat. 

The  carpo-cervical  triangle. 

The  cervico-brachial  triangle. 

The  triangular  cap  of  the  shoulder. 

The  triangular  cap  of  stumps. 

RIGAL’S  BANDAGES  OF  THE  UPPER  EXTREMITIES. 

The  deltoid  bandage. 

13 


194 


SPECIAL,  OR  REGIONAL  BANDAGING. 


A.  Simple  Bandages. 


1. 


Circular  Bandages. 


The  Circular  Bandage  of  a Finger  (Fig.  128).  Composition.— 

A piece  of  muslin  a yard 
FlS- 128-  and  a quarter  long  and 

three-quarters  of  an  inch 
wide. 

Application. — Permit  a 
few  inches  of  the  initial 
extremity  of  the  bande- 
lette  to  remain  free,  ex- 
haust the  balance  of  it  by 
circular  turns  around  the 
finger,  and  knot  the  two 
ends  together.  Or  when 
circular  bandage  of  a finger.  the  initial  end  is  con- 

fined, the  terminal  one 
should  be  split  in  two  a few  inches,  and  then  carried  around  the  finger 
in  opposite  directions  and  tied.  A piece  of  thread  will  answer  the 
same  purpose  of  retaining  the  bandage. 

Use. — The  common  retentive  bandage  in  popular  use  for  injuries 
of  the  fingers. 

The  Circular  Bandage  of  the  Forearm.  Composition. — A 
bandelette  a yard  and  a quarter  long  and  one  inch  and  a half  to  two 
inches  wide. 

Application. — The  initial  extremity  is  confined  to  the  wrist  by  a 
circular  turn,  and  the  bandage  exhausted,  when  the  terminal  end  may 
be  fixed  by  any  of  the  methods  above  mentioned. 

Use. — To  confine  dressings  to  a limited  portion  of  the  forearm. 

The  Circular  Bandage  of  the  Arm.  1s£  Variety. 

The  composition,  mode  of  application,  and  use  of  this  bandage  are 
the  same  as  the  circular  bandage  of  the  forearm. 


2 d Variety,  for  venesection. 

Composition. — A strip  of  muslin  a yard  and  a quarter  long  by  three 
inches  wide,  folded  upon  itself  in  the  direction  of  its  length. 

Application. — Let  the  patient  be  seated  upon  a chair  opposite  the 
surgeon,  Avho  supports  the  hand  of  that  arm  upon  which  the  venesec- 
tion is  to  be  performed,  pressed  against  his  chest;  then  take  the  body 
of  the  bandelette  between  the  fingers  of  both  hands,  and  place  it  about 
an  inch  above  the  point  where  the  puncture  is  to  be  made,  conduct 
its  extremities  backwards,  cross  them  upon  the  posterior  face  of  the 
limb  and  bring  them  forwards,  when  they  are  to  be  tied  in  a single 
bow-knot  upon  the  outer  margin  of  the  arm. 

The  amount  of  constriction  should  be  sufficient  to  interrupt  the 
return  of  blood  in  the  vein,  without  arresting  the  pulsation  in  the 
radial  artery ; for  this  would  defeat  the  object  in  view  by  cutting  off 
the  supply  of  blood  to  the  vein. 

Use. — This  bandage  is  employed  exclusively  in  venesection. 


SPIRAL  BANDAGES. 


195 


§ 2.  Spired  Bandages. 

The  Spiral  Bandage  op  a Finger.  Composition.- — A strip  of 
muslin  a yard  and  a half  long  and  three-quarters  of  an  inch  wide. 

Application. — If  a finger  of  the  right  hand  is  to  be  bandaged,  place 
it  in  a prone  position ; then,  permitting  three  or  four  inches  of  the 
initial  extremity  to  hang  free  from  the  ulnar  border  of  the  wrist,  make 
two  circular  turns  around  this  part;  when  the  roller  arrives  at  the 
fifth  metacarpal  articulation,  cross  the  back  of  the  hand  obliquely  to 
the  radial  margin  of  the  base  of  the  finger  (the  index,  if  you  please), 
which  is  to  be  covered  by  spiral  turns  to  its  point ; and  returning, 
these  are  inclosed  by  circular  turns,  each  of  which  should  overlap  a 
half  of  its  predecessor,  until  the  ulnar  border  of  the  base  of  the  finger 
is  reached,  when  the  roller  passes  obliquely  across  the  back  of  the 
hand,  crossing  the  previous  turn,  to  the  radial  border  of  the  first  meta- 
carpal bone,  and  thence  around  to  the  ulnar  border  of  the  wrist,  where 
the  initial  and  terminal  extremities  of  the  bandage  should  be  knotted 
together. 

Use. — To  make  compression  upon  the  finger,  and  to  retain  dressings 
and  splints  upon  it. 

The  Spiral  of  the  Fingers  (the  Gauntlet)  (Fig.  129).'  Compo- 
sition.— A roller  eight  yards  long  and  three-quarters  of  an  inch  wide. 

Application. — Place  the  hand  in  a position 
of  pronation,  and  if  the  left  hand  is  to  be 
bandaged,  let  three  or  four  inches  of  the 
initial  extremities  hang  free  from  the  radial 
border  of  the  wrist;  then  make  two  circular 
turns  of  this  part,  and  when  the  roller 
arrives  at  the  styloid  process  of  the  radius 
conduct  it  obliquely  across  the  hand  to  the 
ulnar  margin  of  the  base  of  the  little  finger, 
which  is  to  be  inclosed  with  spiral  turns  to 
its  point;  returning,  make  circular  turns, 
each  of  which  ought  to  overlap  half  the 
width  of  its  own  predecessor,  until  the  radial 
margin  of  its  base  is  reached,  when  the  rol- 
ler should  be  made  to  pass  around  the  lower 
part  of  the  ulnar  border  of  the  hand,  across 
its  palm  to  the  radial  border  of  the  wrist; 
whence  it  again  takes  its  departure  to  cross 
the  back  of  the  hand  to  the  base  of  the  ring- 
finger,  which  is  covered  in  the  same  man- 
ner as  the  previous  one,  and  then  the  roller 
returns  again  around  the  ulnar  border  of  the 
hand  across  the  palm  to  the  point  of  departure ; in  this  manner  all  the 
fingers  are  covered  in,  and  the  terminal  end  of  the  bandage  tied  to 
the  initial  end  in  a double  bow-knot  over  the  posterior  surface  of  the 
wrist;  or  the  bandage  may  be  completed  by  circular  turns  around  the 
hand,  as  seen  in  the  figure. 

Use. — To  prevent  adhesions  between  the  adjacent  margins  of  the 

j 


Fig.  129. 


196  SPECIAL,  OR  REGIONAL  BANDAGING. 

fingers  during  the  healing  process  after  burns  ; to  make  pressure  upon 
the  hand  and  fingers,  and  as  a retentive  bandage  in  fractures  and  dis- 
locations of  the  phalanges. 

The  Demi  Gauntlet  (Fig.  130).  Composition. — A roller  five  yards 
long  and  three-quarters  of  an  inch  wide. 

Application. — The  hand  should  be  placed 
in  the  same  position  as  in  the  previous  case, 
and  if  it  be  the  left  one  which  is  being  band- 
aged, let  two  or  three  inches  of  the  initial 
extremity  of  the  roller  hang  free  from  the 
radial  border  of  the  wrist,  which  is  encircled 
twice ; and  when  the  cylinder  arrives  at  this 
point  again,  at  the  end  of  the  second  turn  it 
should  be  conducted  obliquely  across  the 
dorsum  of  the  hand  to  the  ulnar  margin  of 
the  base  of  the  little  finger ; then  in  front  of 
this  and  around  between  it  and  the  ring- 
finger  to  the  ulnar  margin  of  the  hand; 
around  this,  across  the  palm,  to  the  radial 
margin  of  the  wrist,  whence  the  roller 
crosses  the  dorsum  of  the  hand  to  pass 
around  the  base  of  the  ring-finger,  and  back 
again,  as  in  the  previous  turns.  In  this  man- 
ner, pass  around  the  roots  of  all  the  fingers; 
and  finally,  when  the  band  is  exhausted,  knot 
its  extremities  together  over  the  wrist. 

Use. — As  a retentive  bandage  in  disloca- 
tions of  the  first  phalanges  upon  the  metacarpal  bones,  and  also  to 
maintain  dressings  upon  the  back  of  the  hand,  for  which  purpose  it 
is  well  adapted  by  its  simplicity  and  lightness. 

The  Spiral  Bandage  of  the  Fingers  and  the  Hand.  Com- 
position.— A roller  four  yards  long  and  an  inch  and  a half  wide. 

Application. — Place  the  hand  prone,  and  confine  the  initial  extremity 
of  the  roller  by  two  circular  turns  around  the  fingers ; proceed  up- 
wards by  circulars  to  the  base  of  the  thumb,  where  the  irregularity  of 
the  parts  will  demand  more  or  less  reverses,  which  should  be  one  above 
another  in  the  median  line  of  the  hand ; terminate  the  bandage  by 
two  or  three  circular  turns  around  the  lower  portion  of  the  forearm, 
and  pin  the  terminal  end. 

Use. — To  maintain  in  position  apparatus  for  fracture  of  the  bones 
of  the  hand,  and  to  make  pressure  upon  the  parts. 

The  Spiral  of  the  Forearm.  Composition. — A roller  two  yards 
and  a half  long  and  one  inch  and  a half  wide. 

Application. — Confine  the  initial  extremity  by  circular  turns  around 
the  wrist,  then  ascend  the  forearm,  making  the  required  number  of 
reverses  to  permit  the  bandage  to  lie  smoothly  on  the  limb,  and  termi- 
nate by  two  or  three  circular  turns  around  the  lower  portion  of  the 
arm. 

Use. — To  support  topical  applications  upon  the  forearm. 

The  Spiral  Bandage  of  the  Arm.  Composition. — A roller  two 
yards  and  a half  long  and  an  inch  and  a half  wide. 


The  demi-gauntlet. 


CROSSED  BANDAGES. 


197 


Application. — Confine  the  initial  end  below  the  elbow,  and  ascend 
the  arm  by  circular  and  reverse  turns,  until  it  is  entirely  inclosed  to 
the  axilla,  when  the  bandage  is  terminated  by  circular  turns. 

Use. — The  same  as  the  preceding. 

The  Spiral  Bandage  of  the  Whole  Arm  (Fig.  131).  Composi- 
tion.— A roller  twelve  yards  long  and  an  inch 
and  a half  wide.  F's‘  131‘ 

Application.— -As  the  three  preceding  band- 
ages go  to  make  up  the  spiral  of  the  whole  arm, 
or,  in  other  words,  are  so  many  sections  of  it, 
there  will  be  no  necessity  of  describing  it  in 
detail.  It  is  begun  exactly  as  the  spiral  of 
the  hand,  and  terminated  as  that  of  the  arm. 

Care  should  be  taken  to  make  a sufficient 
number  of  reverses  to  enable  the  bandage  to 
embrace  the  limb  evenly  and  neatly. 

Use. — This  bandage  is  often  employed  in 
treatment  of  fractures  of  the  bones  of  the  arm 
and  forearm,  to  prevent  engorgement  of  the 
extremity;  to  make  uniform  pressure  over  a 
large  extent  of  surface  in  inflammatory  affec- 
tions of  the  skin  and  cellular  tissues,  as  in 
erysipelas,  and  especially  where  there  are  large 
collections  of  pus,  detaching  the  integuments 
from  the  subjacent  parts;  to  arrest  hemorrhage 
from  wounded  arteries ; or  to  retard  the  cur- 
rent of  blood  circulating  through  them  in  aneu- 
rismal  cases;  and,  lastly,  to  retain  dressings 
upon  the  whole  extent  of  the  limb  after  scalds 
and  burns. 

§ 3.  Crossed  Bandages. 

The  Crossed  Bandage  of  the  Thumb 
(The  Spica).  Composition. — A roller  two 

yards  and  a half  long  and  two-thirds  of  an 
inch  wide. 

Application. — Let  the  hand  be  placed  in  a 
position  of  pronation,  the  right  hand,  for  in- 
stance, then  permit  three  or  four  inches  of  the 
free  end  of  the  roller  to  hang  from  the  ulnar 
margins  of  the  wrist,  around  which  two  or 
three  circular  turns  are  to  be  made  ; arriving  at 
the  fifth  carpo-metacarpal  articulation,  passing 
from  the  ulnar  to  the  radial  border,  cross  the 
back  of  the  hand  obliquely  to  the  radial  border 
of  the  second  phalangeal  articulation  of  the  thumb,  and  in  front  of  it, 
to  its  ulnar  border,  over  its  dorsum,  crossing  the  previous  turn  at  this 
point,  then  down  around  the  radial  border  of  the  hand  across  the  palm 
of  the  hand  to  its  ulnar  border,  the  point  where  the  first  oblique  turn 


198 


SPECIAL,  OR  REGIONAL  BANDAGING. 


began.  In  a similar  manner  make  a sufficient  number  of  these  turns 
to  cover  in  the  thumb  completely,  each  one  of  which  should  overlap  half 
the  width  of  its  predecessor,  forming  an  ascending  spica.  When  the 
turns  are  made  from  the  base  towards  the  point  of  the  thumb,  the 
spica  is  said  to  be  descending.  Terminate  the  bandage  by  knotting 
the  extremities  together  over  the  back  of  the  wrist. 

Use. — To  keep  dressings  upon  the  thumb,  and  to  make  compression 
in  dislocation  of  the  carpo-metacarpal  articulation.  This  spica  may 
be  applied  in  a similar  manner  to  any  of  the  fingers. 

The  Posterior  Figure  of  8 of  the  Hand  and  Wrist.  Com- 
position.— A roller  seven  yards  long  and  two  inches  wide. 

Application. — Let  the  hand  be  pronated,  the  left,  for  instance,  then 
allowing  three  or  four  inches  of  the  roller  to  hang  free  from  the  radial 
border  of  the  wrist,  make  two  circular  turns  about  this  part ; arriving 
at  the  first  carpo-metacarpal  articulation,  pass  obliquely  across  the 
hand  to  the  base  of  the  little  finger,  then  across  the  palmar  surface 
of  the  first  phalanges,  around  the  radial  border  of  the  index  finger, 
and  back  transversely  over  the  dorsal  surface  of  the  first  phalanges; 
thence  around  to  the  first  metacarpo-phalangeal  articulation,  across  the 
palmar  surface  again  to  the  base  of  the  index  finger;  now  cross  the 
dorsum  of  the  hand  obliquely  to  the  ulnar  margin  of  the  wrist, 
making  a cross  with  the  previous  turn  over  the  metacarpal  bones, 
around  which  one  circular  turn  should  be  made,  when  the  roller  will 
arrive  at  the  radial  margin  of  the  wrist — the  point  of  departure.  Go 
over  this  course  once  or  twice  more,  and  terminate  the  bandage  by 
knotting  the  ends  together  at  the  wrist. 

Use. — For  retaining  dressings  upon  the  posterior  surface  of  the 
hand  and  to  make  compression  upon  that  part  after  dislocation  of  the 
carpal  and  metacarpal  bones ; and  also  upon  ganglionic  tumors  of  this 
region. 

The  Anterior  Figure  of  8 of  the  Hand  and  Wrist.  Com- 
position.— The  same  as  for  the  posterior  figure  of  8. 

Application. — The  turns  of  the  bandage  are  made  in  the  same  gene- 
ral manner  as  in  the  previous  bandage,  only  the  crosses  are  placed  over 
the  palm. 

Use. — To  retain  dressings  upon  the  palm. 

The  Figure  of  8 of  the  Elbow.  Composition. — 1st,  a roller 

bandage  four  yards  long  and  two  inches  wide;  2d,  a square  compress 
of  patent  lint  or  muslin. 

Application. — In  applying  the  figure  of  8 of  the  elbow  to  the  right 
arm,  let  it  be  placed  in  a position  of  supination  ; place  the  compress  on 
the  wounded  vein,  and  then  allowing  three  or  four  inches  of  the  initial 
end  of  the  bandage  to  hang  free  from  the  outer  margin  of  the  arm,  at 
a point  three  inches  above  the  compress,  make  a circular  turn,  and, 
arriving  at  the  outer  margin  of  the  elbow,  conduct  the  roller  obliquely 
over  the  compress  to  the  ulnar  margin  of  the  forearm,  around  the 
upper  part  of  which  one  circular  turn  is  to  be  made,  and  then  passing 
from  its  radial  border  cross  the  compress  again  to  the  inner  margin  of 
the  arm,  and  pass  over  its  posterior  surface  to  its  outer  margin — the 
point  of  departure.  Bepeat  this  course  once  again,  and  terminate  the 


RECURRENT  BANDAGES. 


199 


bandage  by  knotting  the  ends  of  the  roller  upon  the  outer  border  of 
the  arm. 

Use. — To  maintain  a compress  over  a vein  punctured  in  venesec- 
tion. After  the  bandage  is  applied  the  arm  should  be  semi-flexed  and 
carried  in  a sling  until  the  little  wound  made  by  the  lancet  shall  have 
cicatrized. 

The  Extensor  Figure  of  8 of  Arm  and  Hand.  Composition. — 
A roller  six  yards  long  and  two  inches  wide,  wound  in  two  cylinders 
or  heads. 

Application. — Let  the  hand  be  pronated  and  strongly  extended 
upon  the  forearm,  place  the  body  of  the  roller  upon  the  posterior  sur- 
face of  the  hand,  just  above  the  metacarpo-phalangeal  articulation; 
then  conduct  the  two  heads  across  the  palm  in  opposite  directions  and 
bring  them  to  the  dorsum,  where  you  cross  them  with  a reverse,  to  go 
to  the  palm,  whence  they  are  brought  again  to  the  dorsum.  Now 
passing  in  opposite  directions,  one  of  the  heads  is  conducted  around 
the  radial  margin  of  the  hand  obliquely  across  the  forearm  to  the 
outer  condyle,  the  other  around  its  ulnar  border  obliquely  across 
the  former  band  to  the  inner  condyle ; they  are  then  crossed  above 
the  olecranon,  to  be  brought  circularly  to  the  front  aspect  of  the  arm, 
crossed  here,  and  the  upper  turn  reversed  upon  the  lower,  when  they 
are  passed  posteriorly,  and  crossed  above  the  olecranon ; afterwards 
one  roller  courses  along  the  radial  border  of  the  forearm  to  the  ulnar 
border  of  the  hand  and  to  the  palm,  and  the  other  turns  around  the 
inner  border  of  the  arm,  crossing  the  forearm  to  the  radial  border  of 
the  hand  and  palm.  In  this  manner  two  or  three  turns  may  be  made, 
and  the  bandage  exhausted  by  circular  turns  of  the  hand. 

Use. — To  prevent  vicious  cicatrices  of  the  palm  after  burns  pro- 
ducing deformities  of  the  hand. 

The  Flexor  Figure  of  8 of  the  Hand  and  Arm.  Composition. 
— Same  as  the  previous  bandage. 

Application. — The  hand  should  be  in  a state  of  forced  flexion,  and 
the  body  of  the  bandage  placed  upon  its  palm;  the  rest  of  the  bandage 
is  executed  in  the  same  manner  as  the  extensor  figure  of  8. 

Use. — To  prevent  cicatrices  of  the  dorsum  of  the  hand,  producing 
deformity.  * 

§ 4.  Recurrent  Bandages. 

The  Recurrent  Bandage  after  Amputation  of  Arm  and  Fore- 
arm. Composition. — A roller  seven  yards  long  two  inches  wide, 
wound  in  two  heads. 

Application. — This  is  applied  in  the  same  manner  as  the  recurrent 
of  the  lower  extremities  after  amputation. 

The  Recurrent  Bandage  of  the  Shoulder  (after  Disarticu- 
lation). Composition. — A roller  twelve  yards  long  and  two  inches 
wide,  wound  in  two  unequal  heads. 

Application. — Apply  the  proper  dressings,  compresses,  and  a Maltese 
cross  over  the  shoulder,  then  place  the  body  of  the  roller  upon  the 
axilla  of  the  sound  side,  and  bring  the  two  heads  obliquely  across  the 
chest,  one  in  front,  and  the  other  behind,  to  the  acromion  process  above 
the  wound.  At  this  point  the  anterior  cylinder  should  be  reversed 


200 


SPECIAL,  OR  REGIONAL  BANDAGING. 


upon  itself,  and  brought  down  vertically  behind  the  wound,  to  a point 
two  inches  below  it ; the  posterior  cylinder  continues  its  original  course 
across  the  reverse,  and  down  obliquely  from  the  point  of  the  shoulder 
to  the  opposite  side,  and  around  the  chest  circularly  to  cross  the  ver- 
tical turn  of  the  other  head,  which  is  now  reflected  upwards,  so  as  to 
form  a loop  around  the  circular  turn,  to  the  acromion  again.  The 
cylinder  coursing  horizontally  now  passes  in  front  of  the  chest,  around 
the  side,  and  obliquely  over  the  back  to  the  acromion,  to  cross  the 
second  vertical  turn  and  fix  it  above,  while  the  roller  making  the 
vertical  turns  descends  again  over  the  wound.  Continue  in  this  man- 
ner to  make  vertical  turns  with  one  of  the  heads  of  the  roller,  and 
horizontal  and  oblique  turns  with  the  other  until  the  shoulder  is  en- 
tirely covered.  Terminate  the  bandage  by  two  or  three  circular  turns 
around  the  chest. 

Use. — To  retain  dressings  upon  the  shoulder  after  disarticulation. 

§ 5.  Handkerchief  Bandages. 

The  Laege  Quadbilatebal  Scaef  of  the  Arm  antd  Chest. 
Composition. — A piece  of  muslin  about  one  yard  and  an  eighth  long, 
and  two  feet  and  a quarter  broad. 

Application. — Place  one  of  the  long  borders  of  the  piece  of  muslin 
transversely  across  the  chest  and  below  the  breasts;  conducting  its 
angles  posteriorly,  fasten  them  together  over  that  part  of  the  thorax 
opposite  the  injured  side.  Now  raise  the  inferior  border  upwards, 
after  having  bent  the  forearm,  at  an  angle  of  45°,  over  the  whole 
upper  extremity,  and  carry  one  of  its  angles  over  the  shoulder  of  the 
injured  side,  and  the  other  under  the  axilla  of  the  opposite  side,  and 
tie  or  pin  them  together  upon  the  back. 

Use. — This  bandage  answers  the  purpose  of  supporting  the  whole 
arm,  and  retaining  it  in  contact  with  the  chest.  It  may  be  also  ap- 
plied when  the  bandage  of  Desault  is  employed  in  the  treatment  of 
fracture,  that  the  turns  of  the  latter  may  be  pinned  to  it. 

The  Laege  Tbiangulab  Scaef  of  the  Arm  axd  Chest.  Com- 
position.— A piece  of  muslin  a yard  and  one-eighth  square,  folded  in 
a triangle. 

Application. — Place  the  base  of  the  triangle  transversely  across  the 
chest  below  the  mammae,  conduct  its  extremities  posteriorly,  and  tie 
or  pin  them  together  upon  the  side  opposite  the  affected  arm.  Eaise 
its  apex  over  the  arm  after  this  has  been  bent  to  an  angle  of  45°,  or 
any  desired  angle,  and  carry  it  over  the  shoulder  of  the  injured  side, 
to  be  attached  to  the  bandage  behind,  using  a short  strip  of  muslin  if 
it  should  be  not  sufficiently  long  to  reach. 

Use  — This  bandage  will  answer  the  same  indications  as  the  former ; 
but  from  the  fact  of  its  being  double,  is  more  heating  and  is  not  so 
solid. 

The  Large  Oblique  Scarf  of  the  Arm  amd  Chest.  Composi- 
tion.— A piece  of  muslin  a yard  and  one-eighth  square,  folded  in  a 
triangle. 

Application. — Let  the  arm  be  bent  at  an  angle  of  45°  and  directed 
across  the  chest;  then,  taking  the  middle  of  the  base  of  the  triangle 


COMPOUND  BANDAGES. 


201 


in  both  hands,  the  surgeon  glides  it  under  the  elbow  and  along  the 
under  surface  of  the  forearm  to  the  hand.  Its  lateral  extremities  are 
then  conducted  upwards,  one  in  front  of  the  arm  and  chest,  and  the 
other  behind  the  chest,  to  the  shoulder  of  the  healthy  side,  over  which 
they  are  to  be  tied.  How  bring  the  apex  of  the  triangle  around  the 
outer  margin  of  the  arm  and  pin  it  to  the  anterior  extremity. 

Use. — To  sustain  the  arm  and  forearm. 

The  Scarf  of  the  Forearm  and  Heck.  Composition. — A trian- 
gular piece  of  muslin  a yard  and  three- eighths  along  its  base  and  two 
feet  from  base  to  apex. 

Application. — Flex  the  forearm  to  the  desired  angle,  then  glide  the 
base  of  the  triangle  under  the  elbow,  along  the  forearm  to  the  hand, 
and  conduct  its  extremities  upwards,  one  between  the  arm  and  chest 
over  the  shoulder  corresponding  to  the  injured  side,  the  other  over 
the  forearm,  across  the  chest  to  the  opposite  shoulder ; then  tie  or  pin 
them  together  over  the  nape  of  the  neck.  Fold  the  apex  under  the 
elbow  if  it  should  project  beyond  this  point. 

Use. — This  is  the  common  sling  used  to  support  the  forearm  in 
fractures  of  its  bones,  or  in  inflammatory  or  other  diseased  condition 
of  the  hand. 

The  Scarf  of  the  Hand  and  Forearm.  Composition. — A piece 
of  muslin  half  a yard  long  and  8 or  12  inches  wide. 

Application. — Place  the  hand  and  the  lower  part  of  the  forearm 
upon  the  middle  of  the  muslin,  carry  its  ends  upwards,  and  pin  their 
corners  to  the  clothes  over  the  chest. 

Use. — To  support  the  weight  of  the  hand  and  a portion  of  the 
forearm,  in  inflammatory  or  other  diseased  condition  of  these  parts 
requiring  them  to  be  suspended  in  an  elevated  position. 

B.  Compound  Bandages. 

§ 1.  T Bandages. 

The  Simple  and  Double  T Bandages  of  the  Hand.  Composi- 
tion.— A roller  two  feet  and  a half  long,  by  oue  inch  wide : at  right 
angles  to  this,  and  four  inches  from  its  initial  extremity,  if  it  is  desired 
to  form  a single  T,=sew  the  end  of  a strip  of  muslin  two  feet  long  and 
two  thirds  of  an  inch  wide ; if  a double  T is  required,  the  ends  of  two 
such  strips  must  be  tacked  to  the  horizontal  one,  the  first  at  three, 
and  the  second  at  five  inches  from  its  initial  extremity. 

Application. — Give  the  hand  a prone  position,  and  then  place  the 
initial  extremity  of  the  horizontal  band  at  that  part  of  the  wrist 
where,  upon  making  one  circular  turn,  the  two  vertical  strips  will 
correspond  with  the  first  and  fourth  inter-metacarpal  spaces,  one  over 
each ; they  should  then  be  carried  between  the  two  corresponding 
fingers  to  the  palm  and  wrist,  at  which  latter  point  the  circular  band 
passes  around  them.  The  vertical  strips  are  looped  around  it  and 
reflected  downwards,  the  first  one  passing  between  the  index  and 
middle  fingers,  the  other  between  the  middle  and  ring  fingers,  to  the 
back  of  the  hand  and  wrist,  where  they  are  confined  by  being  tied 
together  over  a circular  turn.  The  bandage  is  terminated  by  circular 
turns  around  the  wrist. 


202 


SPECIAL,  OR  REGIONAL  BANDAGING. 


The  single  T is  applied  in  the  same  manner ; the  vertical  strips 
cover  but  two  of  the  metacarpal  spaces. 

Use— A light  retentive  bandage  for  retaining  dressings  upon  the 
dorsum  and  palm  of  the  hand ; and  is  also  used  to  prevent  adjacent 
fingers  uniting  at  their  bases  during  cicatrization  after  burns. 

The  Perforated  T of  the  Hand.  Camposition. — A piece  of 
muslin  ten  to  twelve  inches  long  and  three  to  four  inches  wide,  per- 
forated at  its  middle  by  five  holes  for  the  fingers,  and  having  sewed 
to  one  of  its  ends  the  middle  of  a strip  of  muslin  a foot  and  a half 
long  and  an  inch  wide. 

Application. — Engage  the  fingers  in  the  holes,  and  draw  the  ex- 
tremity having  the  strip  attached  over  the  back  of  th§  hand  to  the 
wrist;  then,  in  like  manner,  arrange  the  other  extremity  upon  the 
palm  and  front  of  the  wrist,  and  fix  them  both,  by  circular  turns  of 
the  strip,  to  this  part;  finally  knot  its  ends  together. 

Use. — Answers  the  same  indication  as  the  preceding  bandage. 

§ 2.  Sling  Bandages. 

The  Anterior  Sling  Bandage  of  the  Hand.  Composition. — 
A piece  of  muslin  sixteen  inches  long  and  three  or  four  inches  wide, 
split  at  each  extremity,  so  as  to  leave  an  intervening  portion  of  three 
inches. 

Application. — Place  the  body  of  the  sling  upon  the  palm  of  the 
hand,  and  tie  its  inferior  extremities  around  the  base  of  the  fingers, 
and  its  superior  ones  around  the  wrist. 

Use. — To  confine  dressings  upon  the  palm  of  the  hand. 

The  Anterior  Sling  of  the  Elbow.  Composition. — A piece  of 
muslin  eighteen  inches  long  and  three  or  four  wide,  split  at  each 
extremity  in  two  tails. 

Application. — Place  the  body  of  the  sling  upon  the  bend  of  the 
elbow,  and  tie  its  inferior  ends  around  the  upper  portion  of  the  fore- 
arm, and  its  superior  ones  around  the  arm. 

The  posterior  sling  is  made  in  the  same  manner;  its  body  is 
applied  over  the  olecranon. 

Use. — To  maintain  topical  applications  upon  the  front  and  back 
aspects  of  the  elbow. 

§ 3.  Sheath  Bandages. 

The  Sheath  for  the  Finger.  Composition. — A sheath  of  muslin 
resembling  the  finger  of  a glove,  large  enough  to  cover  the  finger  and 
the  dressings  upon  it,  and  having  attached  to  the  posterior  portion  of 
its  base  two  threads,  or  a strip  of  muslin. 

Application. — Slip  the  sheath  over  the  finger  and  tie  the  threads 
arouud  the  wrist  to  prevent  its  slipping  off,  or  fix  the  end  of  the  strip 
of  muslin  to  the  same  part,  by  two  threads  attached  to  its  angles. 
The  finger  of  a glove  will  often  answer  the  same  purpose  as  the  sheath. 

Use. — To  maintain  dressings  upon  the  fingers. 

§ 4.  Laced  and  Buckled  Bandages. 

The  Strait  Jacket.  Composition. — A stout  piece  of  canvas,  suf- 
ficiently wide  to  surround  the  trunk  and  long  enough  to  reach  from 


mayor’s  bandages  for  the  upper  extremities.  203 


the  top  of  the  shoulder  to  the  middle  of  the  thighs.  Along  its 
lateral  margins  a series  of  corresponding  eyelet  holes  are  worked,  or, 
what  will  equally  answer,  a number  of  little  loops.  Upon  the  inner 
surface  of  the  canvas,  at  each  side  corresponding  to  the  shoulders,  two 
long  pieces  of  the  same  material  are  sewed,  forming  sheaths  for  the 
arms.  At  the  extremities  of  the  sleeves  holes  are  cut  through  the 
canvas  for  the  hands  to  project  exteriorly,  that  the  pulse  at  the  wrist 
may  be  within  reach  of  the  physician. 

Application. — Slip  the  arms  into  the  sleeves,  and  bring  the  canvas 
up  snugly  around  the  body,  and,  having  drawn  the  eyeletted  margins 
behind,  lace  them  together  with  a stout  cord.  To  still  further  restrain 
the  movements  of  the  patient,  a number  of  loops  may  also  be  fastened 
to  the  top,  bottom,  and  sides  of  the  jacket,  through  which  a cord 
may  be  passed  and  tied  to  the  bedstead.  A more  comfortable  arrange- 
ment is  to  place  the  patient’s  hands  in  leathern  mittens  with  a strong 
loop  at  each  wrist,  through  which  a leathern  strap  passes,  and  buckles 
around  the  patient’s  waist. 

Use. — To  restrain  the  violence  of  the  insane,  and  of  those  un- 
manageable from  delirium  or  other  causes. 

The  Laced  Bandage  of  the  Arm.  Composition—  A piece  of  mus- 
lin three  or  four  inches  wide,  sufficiently  long  to  encircle  the  arm,  and 
perforated  at  its  extremities  by  four  holes  at  equal  intervals.  Take 
two  pair  of  doubled  cords,  one  of  which  is  passed  through  the  two 
upper  holes  in  such  a manner  that  their  extremities  go  in  opposite 
directions  and  leave  a loop  upon  each  margin  of  the  muslin.  Arrange 
the  other  pair  in  the  same  way  in  the  lower  holes,  and  then  knot  the 
four  extremities  together  upon  each  side,  an  inch  from  the  bandage, 
and  cut  off  all  the  ends  but  one. 

Application. — Slip  the  bandage  over  the  arm,  arrange  it  properly 
over  the  dressings  upon  that  part,  and  draw  the  cords  in  opposite 
directions  to  approximate  its  edges,  and  terminate  the  bandage  by 
two  circular  turns  of  the  cords  around  the  arm. 

Use. — To  retain  dressings  upon  the  arm  after  blistering,  applying 
the  moxa,  etc. 

C.  Mayor’s  Bandages  for  the  Upper  Extremities. 

Cravats,  Triangles,  and  Squares  for  the  Fingers,  Hand, 
Forearm,  and  Arm. — Cravats  are  in  popular  use,  and  employed  daily 
for  the  more  trifling  injuries  of  the  arms,  applied  either  circularly 
around  the  parts  or  variously  arranged,  forming  crossed  or  figure  of  8 
bandages  of  the  hand  and  wrist,  and  of  the  elbow.  They  are  fre- 
quently effectual  substitutes  for  the  more  complicated  roller  bandages. 
The  same  remark  applies  to  oblong  pieces  of  muslin,  which  are  applied 
circularly  around  the  limbs,  and  pinned  at  their  corners. 

The  Carpo-Digito-Dorsal  Triangle,  and  the  Carpo-Digito- 
Palmar  Triangle.  Composition.  — A triangular  piece  of  muslin 
twenty  inches  long,  and  ten  inches  from  its  base  to  its  apex. 

Application.- — Place  the  base  of  the  triangle  upon  the  anterior  or 
posterior  aspect  of  the  wrist,  cross  its  angles  behind,  and  tie  them 


204 


SPECIAL,  OR  REGIONAL  BANDAGING. 


together  upon  the  opposite  side;  then  conduct  the  apex  of  the  triangle 
over  the  ends  of  the  fingers  and  palm  of  the  hand  in  the  carpo-digito- 
dorsal  triangle,  and  in  the  reverse  direction  in  the  carpo-digito-palmar 
triangle,  and  pin  it  at  the  wrist. 

Use. — The  first  form  of  the  bandage  is  intended  to  secure  forced 
flexion,  and  the  second  forced  extension  of  the  wrist  and  fingers. 
They  may  also  be  used  as  retentive  means  for  applications  upon  the 
anterior  and  posterior  aspects  of  the  hand. 

The  Interdigital  Triangle.  Composition. — A triangular  piece 
of  muslin  twelve  inches  long  and  eight  inches  high.  A short  distance 
above  its  base  pierce  five  holes  for  the  fingers  to  pass  through. 

Application. — Engage  the  fingers  through  holes,  and  draw  the  base 
of  the  triangle  to  the  wrist,  around  which  its  lateral  angles  are  tied ; 
then,  in  like  manner,  pull  its  apex  down  to  the  wrist  upon  the  oppo- 
site side,  and  pin  it. 

Use. — To  prevent  the  union  of  the  fingers  during  cicatrization  after 
burns ; it  may  also  be  used  as  a retentive  bandage  for  dressings  upon 
the  dorsum  and  palm  of  the  hand. 

The  Palmo-Digito-Brachial  Triangle.  Composition. — 1st.  A 
triangular  piece  of  muslin  a yard  and  an  eighth  long  from  end  to  end, 
and  seventeen  inches  high.  2d.  A cravat,  two  feet  and  a half  long. 

Ajoplication. — Fasten  the  cravat  circularly  around  the  arm  just 
above  the  elbow,  then  place  the  base  of  the  triangle  upon  the  palmar 
surface  of  the  wrist  around  which  its  lateral  angles  are  tied;  conduct 
its  apex  over  the  points  of  the  fingers  placed  in  a position  of  forward 
extension,  and  fasten  it  to  the  cravat  at  the  elbow. 

Use. — The  bandage  is  employed  in  wounds  and  burns  about  the 
wrist,  according  to  the  circumstances  of  the  case,  to  prevent  deformity 
during  cicatrization. 

The  Carpo-Olecranon  Cravats  (Fig.  1B2).  Composition. — Two 
cravats  a foot  and  a half  long,  and  a third  cravat  a }'ard  and  a quarter 
long. 


Fig.  132. 


Application. — Encircle  the  arm  just  above  the  elbow  with  one  of  the 
short  cravats,  and  the  hand  with  the  other ; then  forcibly  extend  the 
hand  upon  the  forearm  and  conuect  the  two  cravats  by  the  long  one 
looped  around  them,  and  tie  its  extremities  upon  the  outer  aspect  of 
the  arm ; or  the  hand  may  be  forcibly  flexed  before  the  third  cravat  is 
arranged. 

Use.  — These  two  forms  of  carpo-olecranon  cravats  are  employed 
as  substitutes  for  the  extensor  and  flexor  figure  of  S bandages  of  the 


rigal’s  bandages  for  the  upper  extremities.  205 

arm  and  hand,  and,  conjoined  with  a short  splint  upon  the  front  of  the 
elbow,  are  used  in  fractures  of  the  olecranon  process. 

The  Carpo-Cervical  Cravats.  Composition. — Two  cravats ; one, 
two  feet  long,  the  other,  a yard. 

Application. — Tie  the  short  cravat  loosely  around  the  neck,  then 
place  the  lower  part  of  the  forearm,  flexed  at  right  angles  with  the 
arm,  upon  the  middle  of  the  long  cravat,  and  conduct  its  extremities 
upwards  and  tie  them  to  the  cervical  cravat. 

Use. — To  support  the  arm,  and  keep  it  flexed  during  the  union  of 
wounds  upon  the  anterior  aspect  of  the  elbow,  or  cicatrization  of  burns 
about  the  olecranon. 

The  Cervico-Brachial  Triangle.  Composition. — A cravat  two 
feet  long,  and  a triangle  a yard  long  and  sixteen  inches  high. 

Application. — Knot  the  cravat  loosely  around  the  neck  with  the  tie 
in  front,  then  slide  the  base  of  the  triangle  under  the  elbow  along  the 
under  surface  of  the  forearm  to  the  hand,  conduct  its  two  lateral  angles 
upwards,  one  upon  each  side  of  the  arm,  and  fasten  them  to  the  cervi- 
cal cravat.  Bring  its  apex  around  the  outer  border  of  the  arm,  and 
fasten  it  to  the  bandage  in  front. 

Use.—' To  support  the  forearm,  and  is  used  as  a substitute  for  the 
scarf  bandages. 

The  Triangular  Cap  for  the  Shoulder.  Composition. — A cra- 
vat two  feet  long,  and  a triangle  a yard  long  and  sixteen  inches  high. 

Application—  Place  the  body  of  the  cravat  in  the  axilla  of  the  sound 
side,  and  tie  its  tails  together  over  the  opposite  shoulder ; then  place 
the  base  of  the  triangle  below  the  wound  upon  the  upper  and  outer 
third  of  the  arm  around  which  its  tails  or  lateral  angles  are  to  be  tied  ; 
the  apex  of  the  triangle  is  then  carried  over  the  point  of  the  shoulder, 
and  fastened  to  the  cravat. 

Use. — To  retain  dressings  upon  the  shoulder. 

The  Triangular  Cap  for  the  Shoulder  (after  Disarticula- 
tion). Composition. — Same  as  in  the  previous  bandage. 

Application. — Fasten  the  cravat  as  was  done  in  the  previous  band- 
age; place  the  base  of  the  triangle  below  the  wound,  then  reflect  its 
three  angles  upwards,  and  fasten  them  to  the  cravat  above  the  shoulder. 

Use. — To  maintain  dressings  upon  the  shoulder  after  disarticulation. 

D.  Rigal’s  Bandages  for  the  Upper  Extremities. 

The  Deltoid  Bandages.  Composition. — A square  piece  of  muslin 
folded  in  a triangle,  and  elastic  cords. 

Application. — Place  the  base  of  the  triangle  upon  the  upper  third 
of  the  arm,  carry  its  lateral  angles  around  this  part  and  knot  them 
upon  its  outer  side;  draw  the  apex  of  the  triangle  towards  the  neck, 
pulling  one  of  its  parts  in  front  and  the  other  behind,  and  tie  them 
together  over  the  sound  shoulder. 

To  render  the  bandage  more  firm,  an  elastic  cord  is  attached  to  the 
margin  of  the  triangle  in  front  and  behind,  passing  beneath  the  sound 
axilla ; a second  elastic  cord  is  tied  anteriorly  and  posteriorly,  to  the 


206 


SPECIAL,  OR  REGIONAL  BANDAGING. 


first  cord  and  above  to  tbe  knot  formed  by  the  tails  of  the  triangle 
upon  the  shoulder. 

Use. — To  retain  dressings  upon  the  shoulder. 

SECTION  I y. 

BANDAGES  OF  THE  LOWER  EXTREMITIES. 

SIMPLE  BANDAGES. 

Circular  Bandages. 

The  circular  bandage  of  a toe. 

The  circular  bandage  of  the  leg. 

Spiral  Bandages. 

The  spiral  bandage  of  a toe. 

The  spiral  bandage  of  the  leg. 

The  spiral  bandage  of  the  thigh. 

The  spiral  bandage  of  the  lower  extremity. 

Figure  of  8 Bandages. 

The  figure  of  8 bandage  of  a toe. 

The  figure  of  8 bandage  of  the  foot  and  leg. 

The  posterior  figure  of  8 bandage  of  the  knee. 

The  anterior  figure  of  8 bandage  of  the  knee. 

The  figure  of  8 bandage  of  both  knees. 

Recurrent  Bandages. 

The  recurrent  bandage  of  the  leg. 

The  recurrent  bandage  of  the  thigh. 

The  recurrent  bandage  of  the  hip. 

Invaginatf.d  Bandages. 

The  invaginated  bandage  for  longitudinal  wounds. 

The  invaginated  bandage  for  transverse  wounds. 

COMPOUND  BANDAGES. 

T Bandages. 

The  single  T bandage  of  the  foot. 

The  double  T bandage  of  the  foot. 

Sling  Bandages. 

The  sling  bandage  of  the  instep. 

The  sling  bandage  of  the  heel. 

The  sling  bandage  of  the  knee. 

Sheath  Bandages. 

The  sheath  bandage  of  a toe. 

Laced  Bandages. 

The  laced  bandage  of  the  lower  extremity. 

MAYOR’S  BANDAGES  FOR  THE  LOWER  EXTREMITY. 

Cravats,  triangles,  and  squares  of  the  toes,  foot,  leg.  and  thigh. 

Imbricated  squares  aud  cravats. 

The  tibial  triangle. 

The  popliteal  cravat. 

The  tarso-patellar  cravat. 

The  compound  metatarso-patellar  cravat. 

The  tarso-pelvic  and  tarso-crural  cravats. 

The  triangular  cap  for  stumps. 

The  triangular  cap  for  the  heel. 

The  metatarso-malleolar  cravat. 

The  malleolar-phalangeal  triangle. 

The  tibio-cervical  cravat. 

The  uniting  cord  for  longitudinal  wounds. 

RIGAL'S  BANDAGES  FOR  THE  LOWER  EXTREMITY. 

The  triangle  of  the  trochanter  major. 

The  bandage  for  the  leg. 

The  bandage  for  the  foot. 


SIMPLE  BANDAGES. 


207 


A.  Simple  Bandages. 

§ 1.  Circular  Bandages. 

The  Circular  Bandage  of  a Toe.— The  composition  and  appli- 
cation of  this  bandage  are  the  same  as  that  of  the  circular  bandage  of 
a finger  already  described. 

The  Circular  Bandage  of  the  Leg  for  Venesection.  Com- 
position.— A slip  of  muslin  a yard  long  and  three  inches  wide,  folded 
in  the  direction  of  its  length. 

Application. — Place  the  body  of  the  bandelette  upon  the  leg  two  or 
three  inches  above  the  malleoli,  conduct  its  extremities  around  the 
limb,  cross  them  upon  its  opposite  side,  and  finally  regain  the  place  of 
departure,  when  they  are  to  be  tied  in  a single  bow-knot  either  upon 
the  inner  or  the  outer  side  of  the  leg,  according  as  the  vein  to  be  punc- 
tured is  upon  the  outer  or  inner  surface  of  the  foot ; the  knot  being 
always  opposite  to  it,  that  the  ends  may  not  be  soiled  nor  interfere 
with  the  flow  of  blood. 

Use. — This  bandage  is  used  exclusively  in  venesection  in  the  foot, 
serving  to  arrest  the  return  of  venous  blood.  It  will  be  necessary  to 
draw  it  pretty  tight ; and  the  foot  may  be  previously  immersed  for 
half  an  hour  in  hot  water  to  facilitate  the  congestion  of  the  veins. 


§ 2.  Spiral  Bandages. 

The  Spiral  Bandage  of  the  Toe. — The  composition  and  appli- 
cation of  this  bandage  are  the  same  as  those  of  a spiral  of  a finger 
already  described. 

The  Spiral  of  all  the  Toes. — The  composition  and  application 
of  this  bandage  are  also  the  same  as  those  of  the  gauntlet  or  spiral  of 
all  the  fingers. 

The  Spiral  of  the  Foot.  Composition. — A roller  four  yards  long 

I and  two  inches  wide. 

Application. — If  the  right  foot  is  to  be  bandaged,  let  the  patient  be 
seated  in  front  of  the  surgeon  with  the  heel  upon  his  knee ; then  make 
two  circular  turns  around  the  ankle  to  confine  the  initial  extremity ; 
when  the  roller  arrives  at  the  external  malleolus,  conduct  it  across 
the  dorsum  of  the  foot  to  the  root  of  the  big  toe ; here  change  its  di- 
rection, and  make  circular  and  reverse  turns  around  the  forepart  of 
the  foot  to  near  the  middle  of  its  outer  border ; now  pass  from  this 
point  up  over  the  instep,  down  its  inner  side,  and  across  the  apex  of 
the  heel  to  its  outer  side,  then  across  the  instep,  again,  and  around 
under  the  heel,  covering  in  the  lower  third  of  the  previous  turns ; in 
like  manner  make  a third  turn  around  the  heel,  which  should  cover 
in  the  upper  third  of  the  first  one ; and  at  the  termination  of  this, 
when  the  roller  comes  to  the  top  of  the  foot,  carry  it  around  its  inner 
border  under  the  sole,  around  the  outer  malleolus  and  the  tendo- 
Achilles,  and  obliquely  upon  the  inner  surface  of  the  os  calcis  across 
the  sole  of  the  foot  to  its  outer  border.  From  this  point  the  cylinder 
comes  obliquely  across  the  instep  around  the  tendo- Achilles  and  over 
the  outer  surface  of  the  os  calcis,  under  the  foot  to  its  inner  margin 


208 


SPECIAL,  OR  REGIONAL  BANDAGING. 


and  up  over  the  instep,  and  round  the  lower  portion  of  the  leg,  when 
the  bandage  is  terminated  by  two  or  three  circular  turns.  In  this 
manner  the  heel  is  perfectly  and  neatly  covered  in,  and  the  entire  sur- 
face of  the  foot  from  the  root  of  the  toes  to  the  leg  compressed  in  a 
uniform  manner. 

Use. — This  bandage  is  employed  almost  exclusively  for  the  purpose 
of  making  compression  upon  the  foot;  when  the  object  is  simply  to 
retain  dressings  upon  the  part,  the  covering  of  the  point  of  the  heel 
may  not  be  so  much  regarded.  In  the  French  spiral,  the  heel  is  left 
exposed,  and  is  very  apt  to  swell,  and  become  painful  from  the  in- 
equality of  the  pressure. 

The  Spiral  of  the  Leg.  Composition. — A roller  seven  yards  long 
and  two  inches  wide. 

Application. — Place  the  patient  in  the  same  position  as  directed  i 
above,  and  confine  the  initial  extremity  about  the  lower  part  of  the 
leg  by  two  circular  turns,  and  then  ascend  to  the  knee  by  circular 
and  reverse  turns,  and  terminate  the  bandage  below  it  by  two  circular 
turns.  When,  however,  uniform  pressure  is  desired,  the  foot  should  ! 
be  included.  In  the  ordinary  spiral  the  initial  extremity  is  confined 
around  the  ankle — we  will  say  the  right — and  the  roller  conducted  j 
from  the  outer  malleolus  across  the  dorsum  of  the  foot  to  the  root  of 
the  big  toe,  then  ascend  the  foot  by  circular  and  reverse  turns  to  the 
anterior  part  of  the  heel,  when  the  roller  courses  over  the  instep  and 
around  the  lower  portion  of  the  leg  which  is  covered  in  to  the  knee  by 
circular  and  reverse  turns.  What  has  been  called  the  French  spiral 
differs  from  the  preceding  in  that  its  initial  extremity  is  confined 
around  the  forepart  of  the  foot  by  circular  turns;  its  succeeding  por- 
tion is  executed  in  exactly  the  same  manner. 

Use. — To  confine  dressings  upon  the  leg,  and  to  make  uniform 
pressure,  as  in  chronic  ulcers  of  that  part,  or  in  diffuse  phlegmonous 
inflammation. 

The  Spiral  of  the  Thigh.  Composition.— A roller  seven  yards 
long  and  two  inches  wide. 

Application. — Place  the  initial  extremity  of  the  roller  upon  the 
lower  part  of  the  thigh,  and  confine  it  there  by  two  or  three  circular 
turns ; then  ascend  towards  the  hip  by  circular  and  reverse  turns,  and  , 
terminate  the  bandage  by  one  or  two  turns  around  the  pelvis. 

Use. — As  a retentive  for  blisters,  poultices,  etc.,  applied  to  the  thigh.  \ 

The  Spiral  of  the  Lower  Extremities  (Fig.  138).  Composition. — 
Two  rollers,  each  eight  yards  long  and  two  inches  wide. 

Application. — If  it  is  the  right  leg,  for  instance,  to  which  we  desire 
to  apply  the  spiral,  proceed  exactly  in  the  same  manner  as  we  have 
directed  for  the  spirals  of  the  foot  and  leg ; and  in  order  to  cover  in 
the  knee,  when  the  spiral  of  the  leg  is  being  finished  and  the  roller 
arrives  at  the  outer  surface  of  the  leg,  instead  of  conducting  it  circu- 
larly around  this  part,  let  it  have  an  oblique  direction  upwards  and 
inwards  over  the  tubercle  of  the  tibia  to  its  inner  side,  across  the 
posterior  aspect  of  the  joint,  and  around  again  in  front,  crossing  the 
previous  turn.  Execute  this  movement  two  or  three  times,  or  until 
the  oblique  turn,  passing  from  without  inwards,  is  on  a level  with  the 


FIGURE  OF  8 BANDAGES. 


209 


Fig.  133. 


patella ; when  the  roller  should  he  "carried  across  the  upper  part  of 
the  popliteal  space,  and  around  the  thigh,  above  the  patella,  to  the 
inner  condyle  of  the  femur.  From  this  point 
the  roller  crosses  the  popliteal  space  again 
obliquely  upwards  and  outwards,  to  pass 
around  the  thigh  in  front  to  the  point  of 
departure,  when  in  crossing  the  above-named 
space  a third  time  the  roller,  passing  obliquely 
downwards  and  outwards,  winds  around  the 
outer  tuberosity  of  the  tibia,  and  crosses  the 
previous  turn  obliquely  to  the  point  above 
the  inner  condyle  of  the  femur,  thus  forming 
a figure  of  8 of  the  knee.  Descending,  make 
three  or  four  of  these  figures  of  8 turns  until 
the  knee  is  entirely  inclosed  ; then  make  one 
circular  turn  around  the  joint  over  the  patella, 
and  gain  the  thigh  which  is  to  be  covered  in 
by  circular  and  reverse  turns  to  the  hip. 

Use. — This  beautiful  bandage  is  employed 
to  make  a uniform  pressure  upon  the  whole 
extent  of  the  inferior  extremity  in  oedema, 
ulcers,  varicose  veins,  inflammation,  and  en- 
gorgements of  that  part ; to  arrest  hemor- 
rhage, and  to  check  the  flow  of  blood  in  aneu- 
rism, and  lastly^,  it  is  used  by  some  surgeons 
in  fractures  of  the  thigh  and  leg. 

The  most  attentive  care  is  necessary,  during 
the  application  of  this  bandage,  that  no  unne- 
cessary degree  of  pressure  be  exerted,  or  gan- 
grene may  be  the  consequence.  Due  allow- 
ance should  also  be  made  for  the  subsequent 
swelling  of  the  injured  limb. 

§ 3.  Figure  of  8 Bandages. 

The  Figure  of  8 of  a Toe. — The  com- 
| position  and  application  of  this  bandage  are 
similar  to  those  of  the  figure  of  8 of  the 
thumb  already  described.  It  should  be  ob- 
, served,  however,  that  the  initial  extremity 
of  the  roller  should  be  confined  around  the 
j anterior  part  of  the  foot,  as  in  the  former  case 
it  is  secured  around  the  wrist. 

Use. — To  retain  dressings,  and  make  com- 
pression upon  the  toe. 

The  Figure  of  8 of  the  Foot  and  Leg. 

, six  yards  long  and  two  inches  wide. 

| Application. — Confine  the  initial  extremity  two  inches  above  the 
malleoli  by  two  or  three  circular  turns ; and  when  the  roller  arrives 
at  the  inner  aspect  of  the  ankle,  conduct  it  across  the  dorsum  of  the 
foot  to  the  fifth  tarso- metatarsal  articulation  : then  pass  beneath  the  sole 
14 


The  spiral  bandage  of  the  lower 
extremity. 

Composition. — A roller 


210 


SPECIAL,  OR  REGIONAL  BANDAGING. 

transversely  to  its  inner  margin,  and  make  one  circular  turn  around 
the  metatarsus,  when  the  roller  should  be  carried  obliquely  across  the 
instep  to  the  outer  malleolus,  and  around  the  posterior  surface  of  the 
leg  to  the  inner  malleolus,  thus  completing  the  figure  of  8.  Go  over 
the  same  course  a second  time,  and  complete  the  bandage  by  circular 
turns  around  the  ankle. 

Use.- — This  bandage  may  be  used  to  retain  dressings  upon  the  ankle, 
instep,  and  sole  of  the  foot ; but  it  is  generally  restricted  to  making 
compression  upon  the  internal  saphenous  vein  after  venesection  at  this 
point. 

The  Posterior  Figure  of  8 of  the  Knee  (Fig.  13d).  Composi- 
tion.— A roller  six  yards  long  and  two  inches  wide. 

Application. — Confine  the  initial  extremity  of  the  roller  three  inches 
above  the  patella  by  two  or  three  circular  turns  around  the  thigh. 

Arriving  at  the  external  con- 
dyle, conduct  the  roller  ob- 
liquely across  the  popliteal 
space  to  the  inner  border  of 
the  tibia,  and  around  the 
anterior  surface  below  its 
tubercle  to  the  head  of  the 
fibula;  from  this  point  make 
one  circular  turn  of  the  up- 
per portion  of  the  leg,  when 
the  roller  should  be  again 
carried  obliquely  across  the 
popliteal  space  to  the  inner  condyle,  crossing  the  previous  turn;  then 
around  in  front  of  the  thigh  to  the  outer  condyle,  thus  completing 
the  figure  of  8.  Repeat  the  same  manoeuvre  again,  and  complete  the 
bandage  by  circular  turns  about  the  lower  portion  of  the  thigh. 

Use. — To  maintain  topical  applications  as  poultices,  etc.  upon  the 
popliteal  space,  and  to  make  compression  upon  the  popliteal  artery, 
an  appropriate  compress  having  been  previously  placed  over  that 
vessel. 

The  Anterior  Figure  of  8 of  the  Knee. — The  composition  and 
application  of  this  bandage  are  similar  to  those  of  the  posterior  figure 
of  8,  only  the  crosses  are  to  be  made  over  the  patella  instead  of  the 
popliteal  space. 

Use. — To  retain  dressings  upon  the  anterior  aspect  of  the  knee. 

The  Figure  of  8 of  Both  Knees.  Composition. — A roller  six 
yards  long  and  two  inches  wide. 

Application. — Having  confined  the  initial  extremity  of  the  roller  to 
the  lower  part  of  one  of  the  thighs  by  circular  turns,  place  the  two 
knees  in  contact,  with  a compress  between  them  to  prevent  their  mutual 
pressure  causing  excoriation,  and  then  proceed  exactly  in  the  same 
manner  as  directed  for  the  execution  of  the  figure  of  8 of  one  knee. 

Use. — To  retain  the  limbs  motionless  in  fracture  of  the  neck  of  the 
femur  and  after  the  reduction  of  dislocation  at  the  hip,  and  also  to 
approximate  the  thigh  in  the  healing  of  a ruptured  perineum. 


Fig.  134. 


The  posterior  figure  of  S of  the  knee. 


RECURRENT  AND  INVAGINATED  BANDAGES.  211 


§ 4.  Recurrent  Bandages. 

The  Recurrent  Bandage  after  Amputation. — The  composition 
and  application  of  the  recurrent  bandages  of  the  arm  and  forearm  are 
identical  with  those  of  the  leg  and  the  thigh  now  to  be  described,  only 
the  number  of  reverses  are  less  numerous  in  consequence  of  their 
smaller  size. 

The  Recurrent  for  the  Thigh  (after  amputation).  Composition. 
— A roller  twelve  yards  long  and  two  inches  wide. 

Application.  — Apply  the  desired  dressings  upon  the  end  of  the 
stump,  and  cover  them  with  a Maltese  cross ; then  confine  the  initial 
extremity  of  the  roller  six  or  eight  inches  above  the  flaps  by  three  or 
four  circular  turns;  coming  to  the  outer  side  of  the  left  thigh,  for 
example,  reverse  the  roller  and  carry  it  perpendicularly  over  the  end 
of  the  stump  to  its  inner  side,  where  another  reverse  is  made  to  give 
it  a circular  direction  around  the  thigh,  passing  from  within  outwards, 
and  making  two  circular  turns  to  confine  the  reverse.  When  the  roller 
arrives  at  the  middle  of  the  anterior  surface  of  the  thigh,  reverse  it  to 
make  a vertical  turn  over  the  centre  of  the  flaps,  and,  coming  to  a 
corresponding  point  upon  its  posterior  surface,  reverse  again,  and 
make  two  circular  turns ; then  cover  in  by  vertical  turns,  first  one 
side,  and  then  the  other  of  the  stump,  securing  the  two  reverses  of 
each  turn  by  two  circulars. 

This  recurrent  can  also  be  effected  with  the  double-headed  roller 
by  placing  its  body  upon  some  point  of  the  circumference  of  the  limb 
six  or  eight  inches  above  the  wound ; conduct  the  cylinders  around 
the  limb  to  the  opposite  side,  where  they  should  be  crossed ; make 
two  circular  turns  in  this  manner,  and  then  give  one  of  the  heads  a 
vertical  direction  to  make  the  recurrent  turns,  which  are  held  by  cir- 
cular turns  made  with  the  other  head. 

Use. — This  bandage  is  employed  to  retain  dressings  upon  the  stump 
of  an  amputated  limb ; that  made  with  the  single-headed  is  more 
simple  but  less  firm  than  that  executed  with  the  double-headed  roller. 

The  Recurrent  of  the  Hip  (after  disarticulation).  Composition. — 
A roller  twelve  yards  long  and  two  inches  wide. 

Application. — Confine  the  initial  extremity  of  the  roller  around  the 
loins  by  two  or  three  circular  turns;  then,  arriving  at  the  outer  sur-" 
face  of  the  hip,  if  it  is  the  right  side,  make  a reverse,  and  conduct  the 
roller  vertically  across  the  wound  over  the  pubis  and  around  the  left 
side  to  the  middle  of  the  right  groin,  where  a reverse  is  made  and  a 
vertical  turn  carried  over  the  centre  of  the  flaps  to  the  posterior  sur- 
. face  of  the  pelvis ; here  another  reverse  becomes  necessary,  to  enable 
the  roller  to  make  two  circular  turns.  Now  proceed  to  cover  in,  first 
; one  side  and  then  the  other  of  the  wound,  by  circular  and  vertical  turns, 
and  finish  the  bandage  by  two  or  three  circular  turns  around  the  waist. 

Use. — To  confine  dressings  upon  the  hip  after  disarticulation. 

§ 5.  Invaginated  Bandages. 

The  Uniting  Bandage  for  Vertical  Wounds  (Figs.  135,  136). 
Composition.—-  1st.  A piece  of  muslin  as  wide  as  the  length  of  the 


212 


SPECIAL,  OR  REGIONAL  BANDAGING. 


wound,  and  long  enough  to  encircle  the  limh  five  or  six  times ; split 
one  of  its  ends  into  three  or  more  heads,  twelve  to  sixteen  inches  lon^ 

O' 


Fig.  135. 


Fig.  136. 


Invaginated  bandage  for  vertical  wounds. 


and  at  a distance  from  their  base  equal  to  the  circumference  of  the 
limb,  perforate  the  cloth  with  a corresponding  number  of  slits.  2d. 
Two  prismatically  graduated  compresses,  somewhat  longer  than  the 
wound  itself,  and  of  a thickness  proportional  to  its  depth. 

Application. — Place  the  injured  extremity  in  such  a position  that 
the  most  perfect  relaxation  of  the  wounded  parts  may  be  obtained ; 
and  to  prevent  engorgement  of  its  lower  portion,  encircle  it  with 
a roller  to  a level  with  the  injury.  Now  apply  the  compresses,  one 
upon  each  side  of  the  incision,  and  from  one  to  two  inches  from 
it ; having  placed  the  body  of  the  bandelette  upon  a part  of  the  limb 
exactly  opposite  to  the  wound,  bring  its  extremities  over  the  com- 
presses, draw  them  in  opposite  directions  until  the  bandage  is  suffici- 
ently tightened,  and  terminate  with  circular  turns. 

Use. — This  uniting  bandage  was  formerly  much  employed  in  the 
treatment  of  vertical  wounds,  but  the  more  effectual  method  with 
adhesive  strips  has  almost  supplanted  it.  Its  use  is  also  restricted 
from  the  rarity  of  wounds  exactly  vertical. 

The  Spiral  Invaginated  Bandage  for  Vertical  'Wounds. 
Composition. — 1st.  Two  graduated  compresses.  2d.  A band  of  vari- 
able length,  proportionate  to  the  volume  of  the  parts,  and  four  fingers 
wide,  wound  in  two  heads. 

Application. — To  apply  the  bandage  upon  a limb,  commence  by 
covering  it  with  a spiral  from  the  fingers  or  toes  up  to  the  wound; 
afterwards  apply  that  portion  of  the  band  intermediate  to  the  two 
cylinders  upon  that  point  of  the  body  or  of  the  limb  which  is  oppo- 
site to  the  wound ; conduct  the  two  cylinders  horizontally  over  the 
inferior  extremity  of  the  wound,  upon  each  side  of  which  a gradu- 
ated compress  is  held  by  an  assistant;  make  in  the  band  of  one  of  the 
cylinders  a slit  that  corresponds  to  the  wound,  and  sufficiently  large 
that  the  opposite  cylinder  can  pass  through  it  easily;  pass  the  cylin- 
der through  this  slit  in  such  a manner  that  the  crossing  of  the  bands 
which  results  rests  over  graduated  compresses ; direct  afterwards  the 
two  cylinders  to  the  point  of  departure,  ascending  a little,  and  making 
a circular  turn  which  covers  two-thirds  of  the  first  one ; having 


/ 


COMPOUND  BANDAGES. 


213 


arrived  at  the  point  opposite  to  the  wound  where  yon  commenced 
the  bandage,  simply  cross  the  cylinders,  reversing  one  upon  the  other; . 
return  over  the  wound,  ascending  still  more,  then  perforate  again  the 
band  of  one  of  the  cylinders  in  the  same  manner,  and  invaginate  them 
as  before;  repeat  this  process  until  the  wound  is  covered,  and  termi- 
nate the  bandage  by  oblique  turns  of  the  neck  and  axilla,  if  it  is  applied 
upon  the  arm,  and  by  circulars  around  the  pelvis  if  to  the.  thigh. 

Use. — -This  bandage  was  used  by  M.  Gerdy  as  a substitute  for  the 
preceding,  believing  it  to  possess  more  advantages  and  to  be  decidedly 
firmer  for  a wound  eight  or  ten  inches  in  length. 

The  Invaginated  Bandage  for  Transverse  W ounds  (Fig.  137). 
Composition. — 1st.  A roller  ten  yards  long  and  two  inches  wide.  2d. 
Two  strips  of  muslin  two  feet  long  and  of  a width  corresponding  to 
the  breadth  of  the  limb.  Split 
the  end  of  one  of  these  strips 
into  three  or  four  heads  a foot 
long,  and  perforate  the  middle  of 
the  other  with  a corresponding- 
number  of  slits.  3d.  Two  pris- 
matically  graduated  compresses. 

Application. — Place  the  limb 
in  a position  most  favorable  for 
relaxing  the  muscles  of  the 
parts,  and  then  lay  upon’  its  an- 
terior aspect  the  two  bandelettes 
with  their  heads  and  fenestras  regarding  each  other ; then  commencing 
below,  secure  these  by  circular  and  reverse  turns  ascending  towards 
the  trunk.  Flow  arrange  the  compresses  and  draw  the  bandelettes 
over  them  in  opposite  directions,  having  previously  slipped  the  heads 
of  the  one  through  the  slits  of  the  other,  when  they  should  be  secured 
1 by  descending  spiral  turns. 

Use. — This  bandage  has  been  employed  in  fracture  of  the  patella, 
rupture  of  the  tendo- Achilles,  and  in  transverse  wounds  of  the  ex- 
: tremities ; but  it  is  now  rarely  used. 

B.  Compound  Bandages. 

§ 1.  T Bandages. 

The  Single  and  Double  T of  the  Foot.  These  bandages  are 
prepared  and  applied  in  the  same  manner  as  the  corresponding  ones 
of  the  hand  already  described. 

Use. — To  confine  dressings  upon  the  upper  and  lower  aspect  of  the 
foot,  and  also  to 'prevent  the  union  of  the  toes  during  cicatrization. 

§ 2.  Sling  Bandages. 

The  Sling  of  the  Instep.  Composition. — A piece  of  muslin  a 
foot  and  a half  long  and  three  inches  and  a half  wide,  split  at  each 
end  in  two  tails. 

Application. — Place  the  body  of  the  bandage  upon  the  instep,  tie 


Fig.  137. 


Invaginated  bandage  for  transverse  wounds. 


214  SPECIAL,  OR  REGIONAL  BANDAGING. 

the  inferior  tails  around  the  foot  and  the  superior  ones  around  the 
lower  portion  of  the  leg. 

Use. — To  maintain  topical  dressings  upon  the  foot. 

The  Sling  of  the  Heel.  Composition. — The  same  as  the  pre- 
ceding. 

Application. — Place  the  body  of  the  sling  upon  the  heel,  fasten  the 
inferior  tails  around  the  forepart  of  the  foot,  and  the  superior  ones 
around  the  inferior  portion  of  the  leg. 

Use. — This  is  a very  simple  retentive  bandage  for  holding  charpie 
or  other  dressings  to  the  heel. 

The  Sling  of  the  Knee  (Fig.  138).  Composition. — A piece  of 


Fig.  138. 


muslin  a yard  long  and  a quarter  wide,  split  at  each  extremity  in  two 
tails. 

Appli cation.- —Lay  the  body  of  the  sling  over  the  patella,  or  popliteal 
space,  tie  the  superior  extremities  around  the  inferior  part  of  the  thigh, 
and  the  inferior  ones  around  the  superior  portion  of  the  leg. 

Use. — To  maintain  dressings  upon  the  knee. 

Fig.  139. 


§ 3.  Sheath  Bandages. 

The  Sheath  Bandage  for  the  Toe. — This 
bandage  is  prepared  and  applied  in  the  same 
manner  as  the  sheath  for  the  finger. 

Use. — This  is  a convenient  manner  of  retaining 
dressings  upon  the  toes. 

§ 4.  Laced  Bandages. 

The  Laced  and  Elastic  Bandages  of  the 
Foot  and  Leg  (Fig.  139). — These  bandages 
were  formerly  most  frequently  made  of  cotton  or 
woollen  cloth,  kid,  buckskin,  or  silk,  with  eyelet 
holes  in  their  lateral  margins,  through  which  a 
long  lacing  cord  passed,  and  bv  means  of  which 
they  could  be  closely  applied  to  the  limb.  At 
present  India-rubber  in  some  of  its  forms  is 
much  more  commonly  employed  in  their  manu- 
facture, and  the  use  of  the  cord  done  away  with. 
The  bandage  seen  in  Fig.  139  is  thus  prepared; 
the  letters  indicate  the  position  of  the  lines  of 
measurement  for  making  the  bandage  by. 


MAYOR’S  bandages. 


215 


Use. — To  make  uniform  compression  of  the  lower  extremities  in 
varicose  dilatation  of  the  veins,  sprains  of  the  ankle  and  knee,  in 
cases  of  loose  cartilages  in  the  latter  joint,  and  when  the  patella  is 
readily  disposed  to  luxation. 

C.  Mayor’s  Bandages  for  the  Lower  Extremities. 

The  Cravat,  Triangle,  Square  Muslin  and  Handkerchief 
may  often  be  advantageously  had  recourse  to  in  various  injuries  of 
the  thigh,  leg,  foot,  and  toes;  their  application  is  simple,  and  needs  no 
special  notice  here. 

Imbricated  Squares  and  Cravats. — These  are  recommended  by 
Mayor  as  substitutes  for  the  spiral  bandage  of  the  lower  extremity, 
and  the  bandage  of  Scultetus.  Their  composition  and  application  are 
obvious. 

The  Tibial  Triangle.  Composition. — A triangular  piece  of  mus- 
lin a yard  long  and  sixteen  inches  from  the  base  to  its  apex. 

Application. — Place  the  middle  of  the  base  crosswise  beneath  the 
patella,  conduct  one  of  the  lateral  angles  around  the  calf  of  the  leg, 
and  pin  it  at  the  upper  part  of  the  bandage ; the  other  angle  should 
be  carried  in  the  opposite  direction  around  the  calf,  and  fastened  over 
the  lower  aspect  of  the  leg.  The  apex  is  now  to  be  drawn  around  the 
calf,  and  pinned  to  the  centre  of  the  triangle  over  the  tibia. 

Use. — This  bandage  may  be  conveniently  used  for  retaining  dress 
ings  upon  the  leg,  such  as  blisters  and  poultices,  &c. 

The  Popliteal  Cravat.  Composition. — A cravat  a yard  long. 

Application. — Place  the  middle  of  the  cravat  above  the  popliteal 
space,  conduct  the  two  ends  forward,  cross  them  over  the  patella  and 
again  over  the  popliteal  space,  and  finally  draw  them  forwards  and 
tie  or  pin  them  together  over  the  tibia. 

Use. — Employed  in  those  cases  in  which  the  posterior  figure  of  8 
of  the  knee  is  indicated. 

The  Tarso-Patellar  Cravats.  Composition. — Three  cravats,  each 
a yard  long. 

Application. — Tie  one  of  the  cravats  loosely  around  the  tarsus,  place 
the  base  of  another  one  upon  the  front  of  the  thigh  above  the  patella, 
cross  its  extremities  over  the  popliteal  space  and  fasten  them  together 
below  the  knee  in  front.  The  middle  of  the  third  cravat  should  loop 
around  the  tarsal  cravat,  and  its  extremities  be  carried  up  under  the 
upper  cravat,  one  upon  each  side,  and  then  reflected  upon  themselves 
and  pinned. 

Use. — This  bandage  is  used  in  fractures  of  the  patella,  and  in  trans- 
verse wounds  of  the  anterior  surface  of  the  ankle. 

The  Compound  Metatarso-Patellar  Cravats.  Composition. — 
1st.  Five  cravats,  each  a yard  long.  2d.  A paste-board  gutter  splint. 

Application. — Arrange  three  of  the  cravats  in  the  same  manner  as 
directed  in  the  tarso-patellar  cravats,  and  raise  the  limb  somewhat 
' above  the  plane  of  the  back,  by  placing  a pillow  under  it ; let  the  gutter 
splint  be  now  applied  beneath  the  knee  and  fastened  with  the  remain- 
ing cravats  to  the  limb,  one  encircling  the  leg  and  the  other  the  thigh. 


216 


SPECIAL,  OR  REGIONAL  BANDAGING. 


Use. — In  fractures  of  the  patella.  It  is  much  more  firm  and  efficient 
than  the  preceding  bandage,  and  should  always  take  the  precedence 
of  it  in  the  treatment  of  this  fracture. 

The  Tarso-pelvic  and  Tarso-crural  Cravats.  Composition. — . 
Three  cravats  each  a yard  long. 

Application. — Fasten  one  of  the  cravats  around  the  tarsus,  a second 
around  the  pelvis;  then  bend  the  leg  upon  the  thigh  and  forcibly 
extend  the  foot  upon  the  leg;  and  loop  the  middle  of  the  third  cravat 
around  the  lower  one,  over  the  sole  of  the  foot : carry  its  extremities 
upwards  under  the  pelvic  cravat  and  knot  them  together.  The  other 
cravat  may  be  fastened  around  the  upper  part  of  the  thigh  (tarso- 
crural)  ; but  this  modification  is  less  advantageous  or  efficient  than 
the  tarso-pelvic  cravats. 

Use. — To  flex  the  leg  in  transverse  wounds  of  the  posterior  aspect 
and  popliteal  space,  and  to  extend  the  foot  in  rupture  of  the  tendo- 
Achilles. 

The  Triangular  Cap  for  Stumps.  Composition. — A triangle  one 
yard  long  and  sixteen  inches  from  base  to  apex. 

Application. — Place  the  base  of  the  triangle  upon  the  anterior  sur- 
face of  the  stump,  conduct  its  extremities  posteriorly,  cross  them 
behind,  and  bring  them  forwards  and  knot  together  in  front;  reflect 
the  apex  over  the  wound,  and  pin  it  over  the  centre  of  the  bandage. 

Use. — With  this  triangle  a stump  of  any  limb  may  be  conveniently 
and  quickly  dressed.  The  cap  may  be  prevented  from  slipping  off 
by  sewing  two  strips  to  its  base  and  fastening  them  around  the  joint 
above,  or  in  the  case  of  the  thigh  and  arm  around  the  pelvis  and  neck. 

The  Triangular  Cap  for  the  Heel.  Composition. — A triangle 
a foot  and  a half  long  and  ten  inches  high. 

Application. — Place  the  base  of  the  triangle  under  the  heel,  conduct 
its  lateral  angles  around  the  instep  and  the  lower  portion  of  the 
leg,  and  tie  them  together  over  the  teudo- Achilles ; turn  the  apex 
upwards  over  the  heel  and  fasten  it  to  the  bandage  behind. 

Use. — Employed  as  a retentive  bandage  for  the  heel. 

The  Metatarso-Malleolar  Cravat.  Composition.  — A cravat 
two  feet  long. 

Application. — Place  the  middle  of  the  cravat  obliquely  across  the 
instep,  carry  the  higher  extremity  around  the  ankle,  and  lower  one 
under  the  sole  of  the  foot  to  the  dorsum,  where  the  ends  should  he 
tied  together. 

Use. — A simple  retentive  bandage  for  dressings  tied  over  the  in- 
step. 

The  Malleolar  Phalangeal  Triangle.  Composition. — A tri- 
angle a couple  of  feet  long  and  a foot  deep. 

Application. — Place  the  middle  of  the  base  of  the  triangle  under  the 
instep,  reflect  its  apex  over  the  toes  to  the  dorsum  of  the  foot,  then 
conduct  the  lateral  angles  up  over  the  instep,  cross  them  to  go  behind 
the  lower  portion  of  the  leg  upon  each  side,  and  cross  them  there ; 
finally  bring  them  forwards  and  pin  them  together  over  the  top  of 
the  foot. 


) 


rigal’s  bandages  for  the  lower  extremities.  217 

Use. — This  triangle  incloses  the  whole  foot,  and  will  serve  an  excel- 
lent purpose  for  retaining  dressings  upon  any  part  of  it. 

The  Tjbio-Cervical  Cravats.  Composition. — 1st.  A cravat  two 
yards  long.  2d.  A triangle  a yard  long  and  two  feet  deep. 

Application. — Apply  the  base  of  the  cravat  upon  the  shoulder  of  the 
sound  side,  conduct  its  extremities  obliquely  across  the  chest  and  tie 
them  together  upon  the  opposite  hip ; then  bend  the  leg  at  right 
angles,  and  glide  the  base  of  the  triangle  under  the  knee  as  far  as  the 
lower  portion  of  the  leg,  where  the  lateral  angles  are  carried  upwards 
and  fastened  to  the  cravat ; the  apex  is  folded  round  the  lower  and 
front  face  of  the  thigh  and  pinned  upon  the  outer  side  of  the  leg. 

Use. — To  support  the  leg  after  fractures  or  sprains,  when  either  the 
patient  desires,  or  the  surgeon  deems  it  necessary  for  him  to  move 
about  upon  a crutch,  an  important  advantage  in  forwarding  the  con- 
valescence of  a patient  in  bad  health  affected  with  a fracture. 

The  Uniting  Cords  for  Longitudinal  Wounds. — Mayor,  in 
longitudinal  wounds  of  the  extremities,  employs  an  arrangement  simi- 
lar to  his  uniting  bandage  for  harelip : it  requires  no  special  descrip- 
tion in  this  place.  In  transverse  wounds,  he  depends  upon  position 
simply  for  the  approximation  of  their  edges. 

D.  Rigal’s  Bandages  for  the  Lower  Extremities. 

The  Triangle  for  the  Trochanter  Major.  Composition. — A 
square  piece  of  muslin  folded  in  a triangle. 

Application. — Place  the  base  of  the  triangle  over  the  right  or  the  left 
hip,  conduct  its  extremities  around  the  body,  and  tie  them  upon  the 
opposite  side ; then  draw  the  apex  downwards,  separate  its  two  angles, 
and  carry  them  around  the  thigh,  one  in  front,  the  other  behind,  to  be 
fastened  together  upon  its  inner  aspect. 

Use . — The  same  as  Mayor’s  cap  for  the  hip. 

The  Bandage  of  the  Leg.  Composition. — A square  piece  of  mus- 
lin folded  in  a triangle. 

Application. — Place  the  base  of  the  triangle  upon  the  leg  below  the 
knee,  conduct  its  extremities  around  it  and  tie  them  together ; then 
draw  down  its  apex  around  the  leg,  separate  its  two  angles  and  tie 
them  around  the  ankle. 

The  Bandage  for  the  Foot. — This  bandage  is  applied  in  the 
same  manner  as  the  cap  for  the  foot. 


PART  II. 


MECHANICAL  BANDAGES  AND  APPARATUS. 

AYe  have  now  considered  the  more  simple  and  frequently  employed 
bandages  in  surgical  practice,  and,  to  continue  this  sketch  of  what  may 
be  called  the  mechanics  of  surgery,  we  shall  devote  a few  pages  to 
those  more  complicated  mechanisms  had  recourse  to  in  the  treatment 
of  the  various  forms  of  deformities  and  deficiencies  to  which  the  human 
body  is  liable  at  all  times,  and  generally  designated  as  mechanical  or 
orthopaedic  bandages  or  apparatus.  Although  they  have  not  had  that 
amount  of  careful  study  and  attention  given  them  by  the  profession 
which  their  real  importance  would  seem  rigorously  to  demand,  yet  it 
must  not  be  supposed  on  that  account  that  they  are  of  little  value. 
On  the  contrary,  if  one  reflects  upon  the  subject  for  a moment,  and 
learns  that  there  are  thousands  of  cases  of  various  kinds  of  deformities 
in  our  country,  particularly  in  our  large  cities,  which  are  remediable 
in  their  earlier  stages  by  the  use  of  properly  constructed  mechanical 
appliances  alone,  and  even  when  further  advanced,  can  be  much  bene- 
fited by  them ; or,  again,  that  there  is  yet  another  and  large  class  of 
such  affections  in  which,  after  an  appropriate  and  timely  use  of  the 
knife  in  dividing  tendons  and  ligamentous  bands,  the  subsequent 
application  of  mechanical  contrivances  will  materially  hasten  a speedy 
and  successful  issue ; he  can  then  form  some  estimate  both  of  their 
importance  and  the  range  of  their  application. 

In  all  cases  of  deformities,  however,  we  should  be  fully  admonished 
that  it  is  in  their  earlier  stages — in  childhood,  indeed — when  important 
and  permanent  success  can  be  secured ; and  hence,  how  important  a 
duty  it  is  for  the  medical  practitioner  to  familiarize  himself  with  the 
subject  of  orthopraxy,  to  recognize  the  earliest  manifestations  of  an 
impending  deformity,  so  that  he  may  be  able,  when  the  opportunity 
presents  itself,  to  rescue  a patient  from  the  deplorable  fate  of  a wretched 
cripple  or  from  an  unseemly  deformity. 


) 


LOSS  OF  PARTS  OF  THE  HEAD  AND  NECK. 


219 


CHAPTER  I. 

APPARATUS  FOR  REMEDYING  THE  LOSS  OF  PARTS. 

SECTION  I. 

LOSS  OF  PARTS  OF  THE  HEAD  AND  NECK. 

Deficiency  of  the  Cranial  Walls. — From  injury  or  operations 
performed  upon  the  skull,  more  or  less  of  its  bony  walls  may  have 
been  destroyed.  In  the  first  instance  the  loss  may  amount  to  several 
square  inches,  as  is  observed  sometimes  in  sabre  and  gunshot  wounds, 
where  the  brain  and  its  membrane,  being  exposed,  may  be  seen  to  rise 
and  fall  with  every  pulsation  of  the  heart.  In  the  operation  of  tre- 
phining, generally  a small  perforation  of  the  bone  only  is  made,  and 
scarcely  requires  any  surgical  interference. 

The  natural  mode  of  cure,  in  such,  cases,  is  the  effusion  of  plastic 
matter  into  the  excavation,  and  its  organization  in  a tough,  strong,  and 
fibrous  membrane  or  fibro-cartilage,  which,  stretching  from  the  edges 
of  the  bone  all  around,  closes  the  opening  and  defends  the  brain  from 
exterior  violence.  This  membrane  becomes  sometimes  ossified,  and 
establishes  a more  effectual  barrier  against  exterior  hurtful  influences. 

In  those  cases  where  the  efforts  of  nature  do  not  succeed  to  a 
sufficient  extent  to  protect  the  parts  beneath,  either  from  some  defect 
in  the  recuperative  powers  or  from  the  extent  of  the  injury,  some 
mechanical  contrivance  becomes  necessary.  An  extremely  simple  one 
consists  of  a metallic  or  gutta-percha  plate,  of  sufficient  size  to  cover 
the  opening  and  rest  upon  its  margins,  and  of  either  a flat  or  a slightly 
concavo-convex  shape,  according  to  the  circumstances  of  the  case, 
and  painted  in  imitation  of  the  scalp. 

There  are  three  modes  of  retaining  it  in  its  proper  situation.  1st. 
By  strings  affixed  to  its  margins  and  colored  to  match  the  hair,  and 
tied  under  the  chin.  2d.  The  plate  may  have  its  edges  perforated 
with  numerous  holes,  by  means  of  which  it  can  be  sewed  to  the  mar- 
gins of  a hole  of  corresponding  size,  cut  in  a skull  cap  of  muslin  or 
other  material,  and  placed  in  such  a manner  that  when  the  cap  is  upon 
the  head  the  plate  will  fit  exactly  over  the  injury.  3d.  The  last  and 
most  elegant  plan  is  to  solder  two  slender  springs  to  the  plate,  which, 
spanning  the  vault  of  the  cranium,  pass,  concealed  under  the  hair, 
to  points  situated  above  the  ears,  where  they  are  provided  with  two 
little  pads.  Should  the  defect  be  upon  one  side,  one  spring  will  often 
support  the  plate  sufficiently  firm  by  taking  its  point  d'appui  above 
the  ear  of  the  opposite  side. 

As  already  stated,  this  plate  is  intended  to  protect  the  brain  after 
the  loss  of  parts  of  its  natural  bony  defensive  walls. 

Deficiency  of  the  Integuments. — It  is  occasionally  necessary  to 


220  APPARATUS  FOR  REMEDYING  THE  LOSS  OF  PARTS. 

deprive  a part  of  its  integuments  for  a longer  or  shorter  time,  as 
occurs  in  establishing  issues  by  the  actual  or  potential  cautery. 

The  back  of  the  neck  is  often  selected  as  the  point  at  which  the 
derivation  is  established  in  diseases  of  the  brain.  An  open  issue, 
intended  to  be  maintained  for  a long  time,  having  been  made,  in  order  to 
shield  it  from  the  irritating  contact  of  exterior  agents,  as  the  stiff  hair 
upon  the  back  of  the  head,  and  the  clothes,  a metallic  or  gutta-percha 
plate  should  be  prepared  as  in  the  former  instance,  slightly  concavo- 
convex,  and  either  fastened  to  the  neck  by  two  strings  tying  in  front, 
or  set  in  the  middle  of  a common  cravat,  when  the  issue  will  be  en- 
tirely concealed. 

A similar  plate  may  be  prepared  for  any  other  portion  of  the  body. 

Deficiency  of  the  Nose. — The  nose  may  be  partially  or  entirely 
destroyed  by  injury  or  disease;  and  plastic  surgery  has  accomplished 
remarkable  results  in  restoring  the  lost  parts  by  the  various  processes 
of  rhinoplasty ; yet  there  are  numerous  cases  where  it  completely  fails, 
or  the  patient  is  unwilling  to  undergo  any  operation  ; and  these  are 
the  cases  for  which  mechanical  surgery  can  do  much  in  providing  an 
artificial  substitute. 

The  nasal  organ  should  be  completely  healed  before  any  mechanical 
contrivance  is  placed  upon  it  intended  to  correct  the  deformity,  to 
restore  timbre  to  the  voice,  and  to  protect  the  nares  from  irritating 
particles  floating  in  the  air  which  may  produce  chronic  inflammation 
and  even  ulcerations  of  its  lining  membrane. 

Artificial  noses  were  formerly  constructed  of  linden  or  willow  wood, 
metallic  plates,  and  papier  machd,  but  the  lightness,  indestructibility, 
and  plasticity  of  gutta-percha  commend  it  highly  for  this  purpose. 

The  artificial  nose  should  be  made  of  comely  shape,  in  fair  propor- 
tion with  the  symmetry  of  the  countenance,  and  artistically  colored. 

To  maintain  it  in  place,  affix  to  its  posterior  edges  two  or  three 
little  springs,  which  may  catch  upon  the  inner  surface  of  the  nasal 
fissure,  or  solder  a long  spring  to  the  apex  of  the  artificial  nose, 
ascending  between  the  eyes  and  spanning  the  cranium,  to  terminate  at 
the  occiput,  where  it  takes  its  point  d'appui  by  means  of  a little  pad. 
Should  the  patient  wear  glasses,  the  top  of  the  nose  may  be  attached 
to  the  bow  arching  across  from  eye  to  eye. 

Sometimes  a small  portion  only  of  this  organ  is  destroyed,  in  which 
case  the  substituted  member  should  exactly  resemble  it,  and  may  be 
held  in  place  by  narrow  strips  of  adhesive  or  isinglass  plaster  stretch- 
ing over  the  cheek  and  side  of  the  nose.  This  of  course  would  be  a 
very  troublesome  plan,  and  it  was  to  remedy  this  that  Mr.  S.  Snell 
invented  the  nose  sketched  below  {Medico-  Chirurgical  Review,  vol.  iii., 
1825),  and  successfully  applied  it  in  the  case  of  an  army  officer  who 
had  lost  the  greater  part  of  his  nose  (Fig.  110).  He  thus  describes  the 
method  of  making  it : “A  correct  model  was  first  taken  of  the  defec- 
tive parts,  which  was  cast  in  brass,  and  upon  which  a thin  gold  plate 
was  accurately  fitted,  in  the  manner  generally  adopted  by  jewellers. 
To  the  inner  surface  of  this  plate,  at  that  part  which  was  to  form  the 
septum,  were  soldered  three  pieces  of  gold  wire,  which  terminated,  each, 
by  a small  flat  plate,  perforated  with  holes,  for  the  purpose  of  sewing 


LOSS  OF  PAETS  OF  THE  HEAD  AND  NECK. 


221 


to  its  outer  surface  a covering  of  India-rubber.  These  gold  wires 
were  rendered  highly  elastic  (Fig.  141). 

Fig.  140.  Fig.  141. 


The  appearance  of  the  face  before  the  artificial 
nose  was  attached. 


“ Upon  the  outer  side  of  the  principal  plate  was  next  fitted  a piece 
of  ivory,  so  as  entirely  to  cover  it;  the  extreme  edges  of  the  ivory  being- 
intended  to  come  in  close  contact  with  the  face.  The  ivory  was  then 
carved  to  the  exact  shape  and  fashion  of  such  a nose  as  appeared  most 
likely  to  be  suitable  for  the  size  and  contour  of  the  face  for  which  it 
was  intended — the  under  part  be- 
ing hollowed  out  to  form  the  nos- 
trils, rendering  it  very  light  and 
thin.  The  gold  and  bone  were 
now  riveted  to  each  other  firmly 
by  small  gold  pins.  The  artificial 
nose  was  then  placed  upon  the 
face,  and  an  artist  colored  it  in  oil, 
so  as  to  resemble  the  surrounding 
parts,  both  in  color  and  character. 

The  nose  was  held  in  its  posi- 
tion upon  the  face  by  three  elastic 
wires  (Fig.  142);  the  two  lower 
ones,  having  a tendency  to  press 
outwards  during  confinement, 
pressed  against  the  lateral  walls 
of  the  nasal  cavity.  The  upper 
spring  having  a similar  tendency, 
pressed  against  the  upper  roof  of 
the  same  cavity.  The  India-rubber 
was  used  for  the  purpose  of  defending  the  parts  from  the  effects  of 
pressure  of  the  springs.” 


Fig.  142. 


The  appearance  of  the  face  with  the  nose  attached. 


222  APPARATUS  FOR  REMEDYING  THE  LOSS  OF  PARTS. 


Gutta-percha  may  be  modelled  in  the  same  manner,  and  will  afford 
a lighter  and  cheaper  nose. 

Deficiency  of  the  Eye. — When  from  injury  or  disease  the 
front  of  the  globe  of  the  eye  is  destroyed  or  its  contents  evacuated,  it 
is  very  desirable  to  remedy  the  deformity  which  is  thereby  caused; 
for  this  purpose  an  elegant  prosthetic  substitute  is  made  use  of,  called 
the  artificial  eye  (Fig  143).  The  art  of  manufacturing  it  was  prac- 
tised at  an  early  period,  and  two  kinds  were  employed  made  of  steel 
plates.  The  first  covered  the  whole  eye,  and  had  eyelids,  irides,  &c., 
painted  upon  its  outer  surface,  and  was  held  in  place  by  steel  springs; 
the  second  resembled  the  eye  now  in  common  use. 

Porcelain  and  glass  are  the  materials  of  which  the  artist  avails  himself 
at  present  for  making  artificial  eyes ; they  are  sec- 
tions of  spheres  of  different  diameters  for  adaptation 
to  orbits  of  varying  size  in  different  persons.  Each, 
case  requiring  some  special  shape,  according  to  the 
extent  of  injury  or  loss  of  the  orbital  contents. 

Considerable  taste  may  be  displayed  in  the  se- 
lection of  an  appropriate  eye,  as  to  the  color  of  the 
iris,  and  the  convexity  of  the  cornea,  to  correspond 
with  the  remaining  organ.  The  selection  should  be  made  from  a 
large  number,  and  judgment  as  to  perfect  adaptability  in  all  respects 
above  mentioned  should  be  given  by  a person  of  experience  and  taste. 
Another  still  more  important  point,  as  regards  the  comfort  of  the 
patient,  is  to  obtain  an  article  'with  perfectly  smooth  edges,  as  a very 
slight  degree  of  roughness  may  cause  irritation,  or  even  inflammation 
of  the  parts. 

Should  the  remnant  of  the  globe  have  the  insertions  of  the  orbital 
muscles  still  intact,  the  artificial  e}re  fitted  to  its  anterior  surface  will 
participate  to  some  extent  in  its  motions,  and  so  closely  resemble  the 
healthy  organ  as  to  render  detection  of  the  substitute  very  difficult,  if 
not  impossible.  On  the  other  hand,  when  the  contents  of  the  orbit  are 
wholly  evacuated  the  eye  will  not  possess  any  motion,  and  its  vacant 
and  fixed  stare  and  want  of  life-like  brilliancy,  as  compared  with  the 
natural  organ,  will  often  give  the  countenance  a disagreeable  expres- 
sion. The  introduction  of  the  eye  should  not  be  attempted  until  cica- 
trization is  completed  and  all  tenderness  of  the  parts  gone ; its  inser- 
tion may  then  be  effected  by  taking  hold  of  the  outer  angle  of  the 
eye  with  the  thumb  and  index  finger  of  the  right  hand,  after  dipping 
it  in  water,  or  a thin  solution  of  mucilage,  and  placing  its  upper  edge 
gently  under  the  superior  lid,  which  has  been  raised  previously  b}’  the 
index  finger  of  the  left  hand,  and  permitted  to  close  upon  the  outer 
surface  of  the  eye ; the  lower  lid  is  now  to  be  depressed  to  receive  its 
inferior  border.  The  pressure  of  the  two  lids  will  effectually  retain 
the  eye  in  its  proper  site. 

The  eye,  at  first,  should  be  worn  only  three  or  four  hours  at  a time, 
until  the  parts  become  accustomed  to  its  presence.  At  night  it  should 
be  removed  and  kept  in  a glass  of  fresh  water,  Avhich  will  prevent 
mucosity  concreting  upon  its  surface. 

The  plan  of  removing  the  eye  when  necessary  is  very  simple.  The 


Fig.  143. 


Artificial  eye. 


LOSS  OF  PARTS  OF  THE  HEAD  AXD  NECK. 


223 


lower  lid  is  depressed,  and  the  head  of  a pin  is  inserted  beneath  its 
edge  and  the  eye  drawn  forwards. 

In  some  cases,  with  the  very  best  and  appropriate  eye,  so  much 
irritation  is  caused  that  the  patient  has  to  abandon  its  use  permanently. 

Deficiency  of  the  Ear. — For  the  replacement  of  a lost  or  muti- 
lated ear,  a substitute  may  be  prepared  either  of  gutta-percha  or  of 
gold. 

In  the  first  case,  a cast  of  plaster  of  Paris  should  be  made  of  the 
sound  ear,  and  from  this  a metallic  matrix  or  mould  is  prepared,  into 
which  the  melted  India-rubber  is  poured ; and  when  hardened,  is  vul- 
canized and  then  painted  to  imitate  the  natural  organ.  Should  it  be 
decided  to  have  a gold  ear,  two  models  are  made,  one  of  the  anterior 
surface  of  the  ear,  and  the  other  of  its  posterior  surface.  Then  fit  two 
thin  gold  plates  upon  these,  and  when  the  proper  shapes  have  been 
attained,  remove  them  from  the  models  and  solder  their  edges  together. 

In  both  instances  the  ear  is  attached  to  the  side  of  the  head  by  a 
short  tube  upon  its  back  fitting  into  the  meatus,  and  held  in  place  by 
a fine  spring  encircling  the  top  of  the  head. 

Deficiency  of  the  Cheeks  and  Lips. — Very  often,  for  the  destruc- 
tion of  parts  of  the  cheeks  and  lips  from  gunshot  wounds,  lupus,  or 
other  causes,  an  artificial  substitute  can  be  easily  made,  which,  when 
carefully  fitted  to  the  parts  and  painted  flesh  color,  not  only  conceals 
the  deformity,  but  prevents  the  escape  of  the  saliva  upon  the  face. 

The  details  of  the  process  will,  of  course,  vary  according  to  the 
nature  and  extent  of  the  parts  destroyed,  but  the  principle  of  con- 
structing substitutes  for  them  is  the  same.  First  prepare  a model  of 
plaster  of  the  lost  portion  ; from  this  are  made  analogous  shapes  of 
gutta-percha  or  metallic  plates,  and  if  necessary,  the  saliva  may  be 
received  in  a little  gutta-percha  pouch,  concealed  under  the  cravat, 
and  connected  by  a tube  of  India-rubber  with  the  substitute  over  the 
buccal  cavity. 

In  extensive  disease  of  the  upper  maxillary  bone  requiring  an  arti- 
ficial palate,  these  plates,  resembling  parts  of  the  cheek  which  they 
are  designed  to  replace,  may  be  connected  with  the  palate  by  little 
metallic  arms. 

Deficiency  of  the  Palate. — The  loss  of  portions  of  the  palate  is 
commonly  due  to  two  sources.  Its  absence  may  be  owing  to  a con- 
genital defect,  constituting  Wolf’s  jaw,  or  it  may  be  destroyed  by 
certain  diseases,  especially  those  of  a syphilitic  nature,  and  lupus. 

The  defect  may  be  confined  to  the  hard  palate  or  extend  to  the 
velum,  so  that  the  natural  boundary  walls  between  the  nasal  and  buccal 
cavities  are  entirely  removed  by  the  ulcerative  process.  In  still  more 
serious  cases,  the  alveolar  process  and  the  body  of  the  superior  maxil- 
lary bone  itself  may  be  involved  to  a greater  or  less  extent. 

The  recuperative  resources  of  the  system  are  sometimes  displayed 
in  a wonderful  manner  by  effecting  the  closing  of  this  palatal  fissure. 
This  should  teach  us  to  avoid  all  kinds  of  surgical  interference  in  such 
cases,  except  the  occasional  use  of  caustic,  until  it  is  certain  that  the 
defect  is  likely  to  be  permanent.  Appeal  is  then  had  to  an  operation 
which  is  often  crowned  with  signal  success ; yet  there  remain  many 


224  APPARATUS  FOR  REMEDYING  THE  LOSS  OF  PARTS. 


cases  not  amenable  to  tbe  treatment  with  the  knife  ; and  in  these,  pro- 
perly constructed,  mechanical  appliances  answer  frequently  in  alien- 
ating the  sufferings  and  annoyances  of  the  patient. 

In  a moderate  fissure  of  the  hard  palate  in  young  subjects,  the  ap- 
proximation of  its  edges  may  sometimes  be  effected  by  a very  simple 
and  ingenious  plan.  Construct  a palatal  plate  of  gold  with  three  clasps 
upon  each  side  to  catch  upon  the  teeth,  then  remove  a slip  along  its 
centre  and  replace  it  by  a piece  of  India-rubber,  which,  when  the  clasps 
are  in  place,  by  its  tension,  will  insensibly  draw  the  sides  of  the  jaw 
together. 

When  all  means  instituted  to  obliterate  the  fissure  fail,  recourse  must 
be  had  to  mechanical  occlusion ; the  agents  used  for  this  purpose  are 
called  obturators. 

One  of  the  simplest  and  oldest  forms  of  an  obturator  is  that  invented 
by  Ambrose  Pare  in  1585.  It  consists  of  a metallic  plate,  generally 
silver,  with  a piece  of  sponge  attached  to  one  of  its  sides  and  intended 
to  be  introduced  through  the  opening  in  the  palate  into  the  nasal 
cavity.  The  absorption  of  moisture  swells  the  sponge,  closes  the 
aperture,  and  effectually  retains  the  plate  against  the  palatal  vault. 
This  obturator  is  easily  arranged,  and  only  requires  removal  two  or 
three  times  a day  to  be  cleansed  from  adhering  mucosities. 

A modification  of  this  is  to  solder  to  the  upper  surface  of  the  plate, 
in  place  of  the  sponge,  a revolving  tenon  bearing  at  its  apex  wing-like 
appendages,  which  are  intended  to  support  the  plate  by  catching  upon 
the  floor  of  the  nares. 

All  of  those  instruments  which  depend  upon  the  pressure  exercised 
by  them  upon  the  surrounding  parts  for  support  have  the  disadvan- 


Fig.  144. 


tage  of  still  further  enlarg- 
the  orifice  in  which  they 
are  placed. 


To  avoid  this  disadvan- 
tage, and  at  the  same  time 
to  prevent  the  secretions 
collecting  in  the  little  pit 
formed  by  the  upper  sur- 
face of  the  plate  and  the 
edges  of  the  fissure,  a drum, 
of  the  exact  size  of  the 
opening  and  sufficiently 
deep  to  render  the  floor  of 
the  nares  flush,  is  soldered 
to  the  plate,  which  is  held 
in  its  proper  situation  by 
clasps  catching  upon  the 
teeth. 


opening 


Artificial  palate  fastening  by  clasps. 


When  the  alveolar  pro- 
cess is  destroyed  and  the 
cavities  of  the  antrum  and 
the  mouth  communicate, 
the  plates  should  be  made 


LOSS  OF  PARTS  OF  THE  HEAD  AND  NECK.  225 

larger,  and  possess  a projecting  rim  upon  which  any  artificial  teeth 
needed  may  be  fastened.  (Fig.  144.) 

The  loss  of  the  velum  is  a more  serious  concern,  as  regards  the 
facility  of  procuring  an  effective  mechanical  apparatus,  yet  the  greatest 
ingenuity  has  been  displayed  by  mechanicians  in  supplying  a substi- 
tute, and  fortunately  not  without  some  success.  It  would  be  useless 
to  follow  the  detail  of,  or  even  to  mention,  the  numerous  obturators 
invented  since  M.  Delabarre,  of  Paris,  first  introduced  his  into  notice, 
of  which  the  former  are  for  the  most  part  modifications. 

It  will  be  proper,  therefore,  only  to  describe,  in  order  to  give  the 
reader  an  idea  of  what  may  be  done  in  the  way  of  a prosthetic  sub- 
stitution for  the  velum  and  uvula,  one  of  the  best  obturators.  There 
is  no  doubt  but  that  all  the  benefit  which  is  possible  to  be  derived 
from  an  appliance  of  this  sort  may,  in  a majority  of  cases,  be  secured 
by  the  artificial  palate  and  uvula  of  Dr.  Hullihen.  It  consists  of: 
“ 1st.  A valve,  made  of  gold  plate,  as  thin  as  it  can  well  be  worked ; 
2d.  A spiral  spring,  about  an  inch  long,  and  of  the  size  usually  made 
for  whole  sets  of  teeth ; 3d.  A slider,  one  inch  and  a half  in  length, 
and  of  the  width  and  thickness  of  a common  watch-spring ; 4th.  A 
plate,  larger  or  smaller,  as  the  case  may  require,  stuck  up  in  the  usual 
way,  to  fit  the  roof  of  the  mouth.  The  size  and  form  of  the  valve  are 
obtained  by  taking  an  impression  of  the  posterior  opening  of  the 
nares:  the  plate  composing  it  should 
1 be  stuck  up  in  two  parts,  front  and 
hack,  which,  when  soldered  together, 
makes  a hollow  body  of  the  form  in 
; Fig.  145,  letter  a.  At  the  upper  end 
of  the  valve  a small  pin  is  soldered, 
the  point  of  which  looks  down- 
wards, and  of  sufficient  thickness 
to  fit  very  tightly  in  one  end  of  the 
spiral  spring.  The  spiral  spring 
must  be  made  of  such  a length  as 
( will  permit  the  valve  to  rest  slightly 
upon  the  upper  surface  of  the  rem- 
nants of  the  lost  velum.  The 
slider  has  a pin  in  the  posterior 
end,  looking  upwards  to  receive  the  other  end  of  the  spiral  spring, 
before  described.  The  anterior  end  of  the  slider  has  a small  button 
looking  downwards ; the  slider 
is  attached  to  the  plate  by  two 
small  clasps,  as  represented  in 
■■  Fig.  146,  b,  b.  The  plate  may 
he  made  to  cover  the  entire 
roof  of  the  mouth,  when  neces- 
sary ; or  it  may  be  made  only 
sufficiently  large  to  permit  the 
mounting  of  the  slider.  These 
different  plates,  when  put  to- 
gether, particularly  if  the  plate 
IK 


Fig.  146. 


The  same.  Lower  view. 


Fig.  145. 


Hullilien’s  artificial  palate  and  uvula. 
Upper  view. 


226  APPARATUS  FOR  REMEDYING  THE  LOSS  OF  PARTS. 

is  to  cover  the  whole  roof  of  the  mouth,  make  a plate  of  the  form 
represented  in  Fig.  145. 

“ Fig.  146  shows  the  attachment  of  the  spiral  spring  to  the  valve  and 
slider,  c,  c.  The  staples  confine  the  slider  to  the  plate,  b,  b — and  the 
button  on  the  end  of  the  slider,  d,  by  which  the  valve  may  be  set  back 
or  forward,  as  desired  by  the  patient,  without  removing  the  plate  from 
the  mouth. 

“Thus  it  will  be  perceived  that  the  peculiarities  of  this  plate  are: 
First,  a valve  to  fit  to  the  posterior  opening  of  the  nares.  Secondly, 
the  attachment  of  this  valve  to  a slider,  by  which  the  patient  is  enabled 
to  adjust  the  valve  while  in  the  mouth,  in  such  a way  as  to  admit 
through  the  nares  just  the  quantity  of  air  desired.  Thirdly,  the 
mounting  of  the  valve  on  a spiral  spring,  which  will  permit  it  to 
vibrate  backwards  and  forwards,  as  the  breath  is  inhaled  or  exhaled ; 
and  also  to  be  moved  by  any  muscular  action  that  may  remain  in  the 
remnants  of  the  lost  velum,  thereby  answering,  to  a great  extent,  the 
purposes  of  a velum.” 

Deficiency  of  the  Chin. — Some  of  the  most  remarkable  cases  of 
loss  of  the  chin  and  inferior  maxillary  bone  are  recorded  in  the  Die- 
tionnaire  des  Sciences  Medicates  and  the  Bulletin  cle  V Academie  de  Mi-de- 
cine  of  the  pensioners  in  the  Hotel  des  Invalides,  at  Paris,  wounded  in 
the  campaigns  of  Napoleon. 

Hutin  gives  an  account  of  a soldier  by  the  name  of  Frenais,  who 
was  wounded,  in  1811,  at  the  battle  of  Albufera,  by  a shot  which 
carried  away  the  chin.  This  man  died  in  1850,  and  there  ivas  ob- 
served no  trace  of  an  inferior  maxillary  bone  until  the  finger  was 
introduced  behind  the  palatal  process,  when  the  remnants  of  the 
ascending  rami  of  the  inferior  maxillary  could  be  felt;  the  tongue 
was  thicker  than  natural,  and  retracted  upon  the  os  hyoides  to  the 
extent  of  a third  of  its  length;  the  deglutition  was  easy,  but  articula- 
tion was  impossible  without  the  assistance  of  the  mask  which  he  wore. 

H.  Larrey  reports  a somewhat  similar  case : the  soldier  was  wounded 
at  the  siege  of  the  citadel  of  Antwerp,  in  1882.  He  could  articulate 
the  vowels  easily,  but  the  consonants  with  difficulty,  and  required  to 
be  fed  with  a vessel  having  a long  spout;  the  saliva  escaped  ex- 
ternally in  large  quantities,  yet  did  not  interfere  with  his  nutrition. 
The  deformity  was  concealed  by  a mask.  There  are  other  cases  of 
like  character  reported. 

The  most  that  can  be  done  for  the  unfortunates  who  are  wounded 
in  this  manner  is  to  conceal  their  disgusting  disfigurement  by  a mask 
made  of  metal  or  vulcanized  rubber,  obtained  from  an  exact  model 
of  the  countenance,  and  resembling  in  shape  the  outline  of  the  lower 
parts  of  the  face,  and  properly  painted.  The  apparatus  may  be  held 
in  place  by  springs  or  straps  encircling  the  head. 

Deficiency  of  the  Teeth. — The  manner  of  manufacturing  and 
fitting  teeth  devolves  upon  the  dentist,  and  therefore  requires  no 
notice  here. 


N 


APPARATUS  FOR  DEFICIENCIES  OF  TEE  TRUNK.  227 


SECTION  II. 

APPARATUS  FOR  REMEDYING  THE  DEFICIENCIES  OF  THE  TRUNK. 

Deficiencies  of  the  Thoracic  Walls. — Deficiency  of  the  tho- 
racic walls  is  exceedingly  rare,  and  always  the  result  of  congenital 
defect;  in  those  cases  which  have  been  observed,  the  defect  was  in  the 
sternum,  a greater  or  less  extent  of  which  never  having  been  deve- 
loped, the  motions  of  the  organs  below  were  exposed  to  view,  afford- 
ing a rare  opportunity  for  the  observation  and  study  of  the  physiolo- 
gist. 

In  such  cases,  if  it  should  be  demanded,  the  construction  and  appli- 
cation of  a defensive  shield  would  be  simple,  as  protection  to  the  parts 
beneath  is  the  desideratum.  A plate  of  metal  or  other  suitable  light 
and  hard  material,  slightly  convex  anteriorly  and  held  upon  the  chest 
by  straps  or  springs,  or  what  would  be  still  more  secure,  fastened 
by  its  margins  to  the  edges  of  a perforation  in  a tightly  fitting  jacket, 
would  answer  perfectly. 

Deficiency  of  the  Abdominal  Walls. — Loss  of  substance  of 
the  abdominal  walls  is  rare,  yet  more  common  than  the  similar  con- 
dition of  the  chest. 

It  may  be  the  result  of  congenital  defect  or  injury,  the  extent 
of  the  deficiency  being  always  more  considerable  in  the  former  case. 
The  case  of  the  man  who  was  in  the  habit  of  exhibiting  himself  annu- 
ally before  the  medical  classes  of  the  different  colleges  is  well  known 
to  many  professional  gentlemen  who  saw  him.  In  this  person  the 
entire  wall  of  the  abdomen  in  the  hypogastric  region  was  absent,  as 
well  as  the  corresponding  portion  of  the  bladder,  whose  surface  was 
exposed,  its  mucous  membrane  and  the  entrance  of  the  ureters  being 
in  prominent  view.  I have  seen  two  other  persons  similarly  affected. 

The  mechanical  apparatus  for  such  a ease  is  also  simple,  consisting 
of  a mask,  or  cap  of  metal  or  vulcanite,  with  an  India-rubber  bag 
affixed  to  its  lower  borders  to  receive  the  urine  as  it  dribbles  away, 
fitting  over  the  pubis  and  hypogastrium,  and  secured  to  the  body  by 
straps,  springs,  or  by  an  abdominal  bandage  to  a perforation  in  which 
the  cap  is  fastened  by  its  margins. 

I have  seen  four  cases  of  wounds  of  the  abdomen,  resulting  from 
stabs,  in  which  the  tendon  of  the  external  oblique  muscle  never  healed, 
the  aperture  being  covered  with  a thin  cicatrix  which  yielded  to  the 
weight  of  the  bowels  when  the  patients  were  in  the  upright  position 
and  allowed  their  protrusion. 

One  of  the  patients  was  rendered  comfortable  by  having  a truss 
applied  with  a broad  flat  pad  upon  its  anterior  extremity  which 
pressed  upon  the  aperture ; one  was  operated  upon  by  a surgeon  who 
inserted  a suture  in  the  margins  of  the  fissure  after  the  skin  was  cut 
through ; the  patient,  after  a narrow  escape  with  his  life,  was  not  bene- 
fited. The  other  two  passed  from  under  my  notice  without  anything 
having  been  done. 

The  celebrated  case  of  Alexis  St.  Martin  is  well  known,  and  the 
mechanical  appliance  that  would  have  been  proper  for  him  is  evident. 


228  APPARATUS  FOR  REMEDYING  THE  LOSS  OF  PARTS. 

Deficiency  of  the  Walls  of  the  Spinal  Canal. — In  the 
development  of  the  vertebrae,  ossification  in  the  bodies  begins  at  the 
extremities  of  the  spinal  column  and  advances  towards  its  middle,  so 
that  defect  in  them  from  arrested  growth  would  be  found  in  the  dorsal 
region,  while  the  laminae  are  ossified  from  the  middle  of  the  spinal 
column  towards  its  extremities,  so  that  imperfect  development  of  the 
spinal  canal  is  found  in  the  cervical  and  lumbar  region,  and  more 
often  in  the  latter.  This  is  denominated  spina-bifida,  or  hydrorachitis. 

The  membranes  of  the  cord,  not  being  supported,  bulge  externally 
and  form  an  elastic  tumor,  varying  in  size  from  a pigeon’s  egg  to  an 
orange,  or  even  larger,  filled  with  the  synovia-like  fluid  commonly 
contained  in  the  spinal  canal. 

This  disease  is  congenital,  and  the  only  surgical  interference  proper, 
or  at  least  likely  to  be  attended  with  success,  is  compression  by  means 
of  a properly  constructed  instrument  resembling  a truss,  and  furnished 
at  one  of  its  extremities  with  a padded  metallic  disk  which  will  permit 
an  accurate  and  uniform  pressure  to  be  exercised  over  the  whole  sur- 
face of  the  tumor. 

SECTION  III. 

APPARATUS  FOR  REMEDYING  DEFICIENCIES  OF  THE  UPPER  EXTREMITIES. 

Deficiency  of  the  Arm. — It  is  not  intended,  under  this  head,  to 
give  any  lengthened  account  of  the  history  and  construction  of  artificial 
arms,  although  the  subject  is  one  of  considerable  interest  and  utility 
to  military  surgeons,  and  to  practitioners  in  the  country.  Inasmuch  as 
they  are  often  consulted  upon  the  selection  of  a proper  prosthetic  sub- 
stitute, it  may  be  of  essential  service  for  them  to  know  the  proper 
method  of  taking  appropriate  measurements  for  the  artist  to  work  by 
in  turning  out  a nicely  fitting  limb,  and  of  its  construction  and  appli- 
cation. An  additional  reason  for  their  acquiring  some  information  in 
respect  to  this  matter  is,  that  they  may  contribute  considerably  to  a 
patient’s  interest  and  comfort,  by  taking  advantage  of  opportuni- 
ties, sometimes  offered,  of  obtaining  that  length  of  stump  best  suited 
for  the  adaptation  of  the  most  effective  and  useful  mechanical  contri- 
vance. 

It  is  an  interesting  fact  that  the  first  effort  made  to  provide  artificial 
limbs,  of  which  we  have  any  accurate  account,  was  by  Ambrose  Pare, 
surgeon,  successively  to  Henry  II.,  Charles  IX.,  and  Henry  IV.  of 
France.  In  his  works,  published  about  the  middle  of  the  sixteenth 
century,  he  describes  an  artificial  arm,  which  was  made  for  him  “to 
his  great  cost  and  charges,  by  a most  ingenious  and  excellent  smith, 
dwelling  at  Paris,  who  is  called,  of  those  who  knew  him,  and  also  of 
strangers,  by  no  other  name  than  the  little  Lorrain.” — Les  (Euvres 
d'  Ambrose  Pare,  p.  677. 

The  framework  of  the  arm  was  constructed  of  sheet-iron,  with  ap- 
propriate springs  in  its  interior  for  moving  the  fingers,  wrist,  and 
elbow,  and  was,  therefore,  very  heavy,  so  that  but  few  could  wear  it  for 
a long  period  continuously. 

This  arm,  though  not  comparable  to  the  artistic  productions  of  the 
present  day,  redounds  much  to  the  ingenuity  and  humanity  of  the 


APPARATUS  FOR  THE  UPPER  EXTREMITIES. 


229 


great  French  surgeon,  who  was  always  nobly  striving  to  alleviate  the 
misfortunes  and  ills  of  mankind,  by  the  invention  of  new,  or  more  im- 
proved apparatus,  and  surgical  processes. 

Gotz  von  Berlichingen,  of  Nuremberg,  invented  an  arm  and  hand 
made  of  iron,  similar  in  mechanism  to  that  of  Pare,  but  much  lighter, 
and  so  far,  was  a positive  improvement.  Beyond  this,  little  progress 
was  made  until  1812,  when  Mr.  Bailiff,  of  Berlin,  happily  constructed 
an  arm  and  band,  weighing  nearly  a pound,  which  could  seize  upon  small 
objects  with  fingers  put  in  action  by  concealed  gut  cords  fastened  to  the 
phalanges  below,  and  connected  above  by  a cord  to  the  upper  border 
of  the  sheath,  and  by  the  tension  of  which  the  fingers  were  moved  by 
overcoming  the  resistance  of  small  springs  placed  upon  their  palmar 
aspects. 

In  1845,  Van  Peterson,  of  Berlin,  surpassed  all  his  predecessors  in 
producing  an  artificial  limb  of  extraordinary  ingenuity,  and  was  the 
subject  of  a report  of  a commission  of  the  Academy  of  Sciences,  Paris, 
composed  of  Velpeau,  Payer,  Magendie,  and  Gambey.  These  gentlemen 
selected  for  experiment  an  old  soldier 
who  had  lost  both  arms,  and  upon 
whom  the  artificial  limbs  of  Peterson 
were  placed  as  seen  in  Fig  147. 

The  mechanism  of  motion  consists 
of  gut  cords,  which  are  fixed  above  to 
a corset,  and  below  to  the  front  of  the 
forearm  and  to  the  dorsal  aspect  of  the 
fingers,  each  of  the  latter  possessing 
three  articulated  phalanges,  and  held 
in  apposition  by  their  points  with  the 
tip  of  the  thumb  by  springs.  When 
the  person  moves  his  stump  forwards, 
the  cord  A,  passing  between  the  corset 
and  forearm,  being  made  tense,  draws 
the  latter  up,  and  flexes  it  upon  the 
arm,  by  which  movement  the  hand 
may  be  carried  to  the  mouth ; back- 
ward movement  of  the  stump  extends 
the  arm  again.  The  cord  B is  attached 
to  the  corset  at  the  point  marked  3.  and, 
passing  around  a pulley  in  the  fore- 
arm, is  connected  with  the  extending 
cords  of  the  fingers,  in  such  a manner 
that  when  the  stump  is  abducted  it 
draws  upon  the  fingers  and  extends  them,  which  immediately  resume, 
by  means  of  the  springs  placed  upon  their  palmar  surfaces,  their 
original  position  of  apposition  with  the  thumb  by  approximating  the 
stump  to  the  chest. 

The  motions  of  the  natural  limb  were  still  further  imitated  by 
Charrihre,  of  Paris,  under  the  direction  of  M.  Huguier.  As  seen  in 
the  figure  (Fig.  148),  this  apparatus  consists  of  a laced  armlet  articu- 
lated with  a forearm  of  stiff  leather  composed  of  two  sections,  the 


Fig.  147. 


Tan  Peterson's  artificial  arm. 


230  APPARATUS  FOR  REMEDYING  THE  LOSS  OF  PARTS. 


latter  being  also  movably  articulated  with  a carved,  hollow  wooden 
hand,  provided  with  fingers  made  of  steel  and  covered  with  wood,  and 
sufficiently  firm  to  retain  the  position  in  which  they  are  placed. 

The  armlet  intended  to  embrace  the  stump  is  fastened  above  to  a 
corset  or  shoulder-cap.  Motion  is  impressed  upon  the  limb  by  the 
movements  of  the  stump  acting  upon  a catgut  cord  taking  a fixed 
point  above  the  shoulder-cap,  and  attached  below  to  the  forearm.  By 
abducting  the  stump,  the  cord  A flexes  the  forearm,  and  through  this 
movement  the  wrist  also  by  means  of  the  cord  D extending  between  the 
eccentric  projecting  posteriorly,  from  the  inner  hinge  of  the  elbow,  and 


Fig.  148. 


Fig.  149. 


Mechanism  of  pronation  of  Charriere’s  artificial  arm. 

the  anterior  margin  of  the  hand,  into  which 
it  is  inserted  at  F by  means  of  a short  spiral 
spring.  When  the  stump  again  resumes  its 
position  by  the  side  of  the  chest,  and  the 
cords  A and  D are  relaxed,  the  elastic  bands 
G extend  the  forearm,  and  at  the  same  moment 
the  spiral  spring  extending  between  the  points 
I and  H causes  the  hand  to  execute  the  same 
movement.  By  pressing  upon  one  of  the 
projections  J,  with  the  other  hand  or  hip,  the 
movements  of  pronation  and  supination  may 
be  impressed  upon  the  limb.  There  is  also  an- 
other provision  made  for  these  motions  by  a mechanism  attached  to  the 
external  hinge  of  the  elbow  at  M,  Fig.  149  ; it  consists  in  an  eccentric, 
N,  moved  by  a sectional  cog-wheel,  M,  that  it  may  be  made  to  complete 
one  whole  revolution  by  the  complete  flexion  of  the  forearm : to  the  end 
of  this  eccentric  the  cord  o is  fastened  above,  and,  passing  downwards, 
enters  an  aperture  in  the  forearm,  goes  around  the  pulley  P,  and  finally 
is  terminated  by  being  attached  to  one  of  the  cross-bars  of  the  forearm 
at  the  point  T,  so  that  when  the  forearm  has  executed  half  the  movement 


Artificial  arm  of  Charriere. 


APPARATUS  FOE  THE  UPPER  EXTREMITIES. 


231 


of  flexion  the  eccentric  also  completes  half  a revolution,  and  ascends  to 
a position  parallel  with,  the  arm,  drawing  the  cord  o to  its  extreme  degree 
of  tension,  and  necessarily  supinating  the  forearm.  The  flexion  being 
still  further  increased,  the  eccentric  descends  towards  its  original  posi- 
tion, relaxing  the  cord  o,  and  permits  the  spiral  spring  s,  passing  around 
the  pulley  B and  attached  to  the  cross-bar  at  T,  to  bring  the  arm  into 
pronation  again.  In  extension  of  the  limb,  again,  the  eccentric  first 
supinates  and  then  pronates  the  forearm  as  before.  By  the  same 
mechanism  extension  of  the  fingers  may  be  produced. 

Another  artificial  limb,  equalling  the  preceding  in  ingenuity,  was 
invented  by  M.  Bechard,  and  is  thus  described  by  Bigg : — - 

“The  point  of  support  is  a laced  sheath  carried  by  two  iron  splints 
adapted  to  the  arm.  The  articulation  of  the  elbow  presents  nothing 
particular.  The  forearm  and  hand  consist  of  three  movable  pieces  of 
hollow  wood. 

“1st.  The  upper  portion  is  fixed  by  means  of  the  two  splints  which 
serve  for  the  articulation  of  the  elbow  and  terminate  there.  2d.  The 
second  portion,  entirely  of  wood,  corresponds  to  the  lower  two-thirds 
of  the  whole  length ; it  carries  at  its  upper  part  a movable  chariot, 
rolling  by  means  of  bone  castors  which  slide  on  a circular  plate  of 
iron,  so  that  the  movements  are  very  smooth.  This  arrangement 
allows  this  portion  to  move  on  the  upper  one  through  a quarter  of  a 
circle,  and  this  motion,  being  transmitted  to  the  whole  lower  part, 
simulates  the  rotation  of  the  limb  outwards. 

“ The  limb  is  maintained  in  the  normal  state  of  pronation  by  a spiral 
spring  fixed  at  the  top  of  the  piece  in  the  centre  of  the  chariot,  the 
permanent  action  of  which  acquires  all  its  force  when  all  pulling 
ceases.  To  explain  this  mechanism  more  fully,  a single  cord  of  gut, 
starting  from  the  top  of  this  piece  and  communicating  with  the  chariot 
by  means  of  two  small  pulleys,  goes  up  along  the  amputated  limb, 
passes  behind  the  shoulder,  and  reaches  obliquely  the  circular  band 
of  the  trowsers  at  the  braces  of  the  opposite  hip. 

“When  the  arm  is  abducted,  this  cord,  being  stretched,  acts  on  the 
chariot,  which,  rotating  on  its  axis  for  a quarter  of  a circle,  carries 
with  it  all  the  lower  part  of  the  apparatus,  rotating  it  outwards ; that 
is  to  say,  supinating  it.  When,  on  the  contrary,  abduction  is  replaced 
by  adduction,  the  spiral  spring  we  have  mentioned  gets  in  action,  and 
brings  back  the  arm  by  a reverse  movement  into  its  normal  position ; 
that  is  pronation. 

“The  second  piece,  which  performs  this  movement  of  rotation  over 
a quarter  of  a circle,  carries  in  the  centre  of  the  upper  plate  which 
terminates  in  a straight  rod,  which  descends  through  its  interior  in 
the  direction  of  its  axis.  This  rod,  which  for  a sufficient  length  is 
surrounded  by  an  endless  screw,  supports,  on  a level  with  that  screw, 
a horizontal  box,  which  it  raises  during  supination  and  lowers  during 
pronation.  The  box  itself  carries  at  its  extremities  two  parallel 
branches  of  iron,  which  terminate  a little  above  the  wrist-joint  in  two 
transverse  metallic  button-holes.  These  button-holes  enter  a segment 
corresponding  to  each  of  them,  cut  out  of  the  iron  plate  which  termi- 
nates this  second  piece ; they  are  connected  with  the  pulling  of  the 


232  APPARATUS  FOR  REMEDYING  THE  LOSS  OF  PARTS. 

fingers.  As  the  action  of  the  endless  screw  on  the  box  is  manifested 
during  rotation,  the  two  branches  which  terminate  it,  rising  during 
supination,  act  on  the  extensor  tendons  of  the  fingers  and  bring  them 
into  action. 

“ The  third  improvement  is  much  more  important,  and  consists  in 
this:  The  hand  which  is  at  the  end  of  the  artificial  arm  being  exposed, 
when  used,  to  all  kinds  of  frictions,  gets  easily  dirty;  and  then  it  is 
necessary,  according  to  circumstances,  in  order  that  the  imitation  be 
perfect,  that  it  should  be  naked  or  gloved. 

“After  a good  many  trials,  M.  Bechard  discovered  a method  of  un- 
hooking the  wrist,  by  means  of  a pressure  made  with  the  other  hand 
on  a button  hidden  under  the  coat-sleeve.  It  will  be  easily  conceived 
that  much  patience  was  required  in  order  to  succeed  in  combining  a 
system  admitting  of  the  arm  being  completely  taken  to  pieces,  of 
changing  the  hand,  and  of  instantaneously  resembling  the  actions  of 
the  extensor  and  flexor  tendons.  With  this  view,  the  union  of  the 
Avrist  with  the  second  piece  of  the  arm,  the  mechanism  of  which  has 
been  described,  is  effected  a little  above  the  place  occupied  by  the 
radio-carpal  joint  below,  by  means  of  a double-toothed  pinion  enter- 
ing a mortice  hollowed  out  of  the  lower  surface  of  the  second  bra- 
chial piece.  On  each  side  of  this  pinion  are  two  prominent  buttons, 
with  conical  heads  above  a smaller  neck,  which  correspond  to  the 
pulleys  of  the  fingers,  divided  into  two  bundles.  Both  parts  are  joined 
together  by  making  the  pinion  obliquely  enter  the  mortice ; the  wrist 
is  then  made  to  rotate  over  a quarter  of  a circle,  in  the  same  way  as  a 
bayonet  is  fixed  ; and  when  the  rotation  is  completed,  the  two  metallic 
buttons  come  and  hook  into  the  two  horizontal  button-holes,  which  ter- 
minate the  two  branches  of  the  mobile  screw-box  indicated  above. 

“ Lastly,  the  fingers,  carefully  carved  out  of  wood,  show  no  mechan- 
ism externally ; all  is  in  the  interior.  M.  Bechard  does  away  with  the 
cord  of  gut  as  the  acting  force,  and  with  spiral  springs  as  the  resisting 
force.  A simple  flexible  steel  plate,  placed  inside,  and  half  flexed,  is 
arranged  in  such  a manner  that  by  pulling  on  the  upper  part  it  pro- 
duces extension,  and  the  reverse  movement,  when  it  ceases  to  act. 
The  thumb  alone  is  moved  (by  means  of  two  reflecting  pulleys  con- 
necting it  with  the  common  traction)  in  such  a manner  that  when  the 
fingers  are  extended  it  performs  the  same  movement,  and  is,  besides, 
abducted,  in  order  to  return  to  the  flexed  position,  and  is  abducted 
when  at  rest.  Furthermore,  care  has  been  taken,  not  only  to  put  in 
its  anatomical  place  the  metacarpo -phalangeal  articulation,  but  also 
to  imitate  the  longitudinal  grooves  which  separate  them ; this  has 
never  been  done  before,  and  detracted  from  the  shape  of  the  hand,  ren- 
dering it  uunatural  and  ungraceful.7’ 

“ The  preceding  description  applies  to  an  apparatus  intended  to 
replace  the  forearm,  amputated  below  the  elbow." 

If  it  is  required  to  replace  a limb  amputated  through  the  lower  part 
of  the  humerus,  or  through  the  elbow-joints,  an  armlet  is  added  which 
embraces  the  upper  part  of  the  opposite  arm.  This  arm-piece  serves 
to  give  attachment  to  a traction  string,  which  passes  transversely  from 
one  shoulder  to  the  other,  and,  after  coming  down  along  the  appara- 


APPARATUS  FOR  THE  UPPER  EXTREMITIES. 


233 


tus,  ends  at  the  upper  and  inner  part  of  the  forearm.  This  string  is 
destined  to  produce  flexion  of  the  elbow.  It  is  moderately  tense  in 
the  normal  position  of  a man  who  is  standing,  and  acts  when  the 
sound  arm  is  abducted ; on  the  two  points  of  attachment  becoming 
more  distant,  the  elbow  is  flexed. 

These  arms  now  described  are  models  of  mechanical  ingenuity  and 
elegance  of  finish,  and  have  been  the  groundwork  upon  which  Euro- 
pean mechanicians  have  labored  to  obtain  other  less  complicated  and 
less  expensive  limbs,  so  as  to  bring  them  within  the  reach  of  all 
classes  of  persons  who  have  had  the  misfortune  to  lose  an  arm. 

The  mechanical  and  artistic  ingenuity  of  America  has  not  lagged 
behind  that  of  our  transatlantic  brethren.  Artificial  arms  are  now 
manufactured  here  which  combine  both  exquisite  workmanship,  and 
all  the  really  useful  functions  which  such  a mechanism  can  perform, 
at  a comparatively  moderate  expense. 

The  artificial  arm  of  Mr.  Gildea,  of  Philadelphia,  for  amputation 
below  the  elbow,  is  an  excellent  contrivance ; aud  for  durability,  neat- 
ness of  finish,  and  efficiency  cannot,  I think,  be  surpassed  by  any  yet 
invented ; its  mechanism  is  simple,  and  not  liable  to  get  out  of  order ; 
it  is  modelled  in  exact  imitation  of  the  natural  limb ; made  of  willow, 
and  elegantly  enamelled.  At  the  metacarpo-phalangeal  articulations 
the  fingers  are  solidly  connected  together  by  a transverse  bolt,  which 
allows  antero-posterior  motion  only;  the  fingers  are  carved  from  a solid 
piece  of  wood,  and  are  in  a position  of  semi-flexion,  the  index  oppos- 
ing the  thumb,  and  the  little  finger  forming  a sort  of  a hook;  the 
thumb  is  movable  both  at  the  metacarpo-phalangeal  and  phalangeal 
joints. 

The  mechanism  of  motion  consists  of  a metallic  rod,  which  is  con- 
nected at  its  lower  extremity  to  the  base  of  the  middle  finger,  and  at  its 
upper  to  the  end  of  a short  lever,  which  has  a fulcrum  at  the  centre  of 
the  hand,  and  projects  towards  its  ulnar  border,  where  a spiral  spring 
connects  it  with  the  base  of  the  little  finger.  Parallel  with  this  lever, 
and  above  it,  is  a second  lever,  fastened  by  a fulcrum,  at  one  end  to 
the  ulnar  border  of  the  hand ; a little  to  the  outer  side  of  this  point 
there  is  a tenon,  between  which  and  the  inner  extremity  of  the  second 
lever  a piece  of  wire  extends,  coupling  the  two  levers  together;  a 
short  distance  from  the  tenon,  the  upper  end  of  the  extensor  cord  of 
the  thumb,  which  is  of  catgut,  is  attached.  A long  steel  strip  passes 
from  the  outer  extremity  of  the  upper  lever,  externally,  through  a 
perforation  upon  the  radial  border  of  the  forearm,  and  is  extended  to 
the  upper  arm-band  by  a strap  and  buckle ; the  thumb  is  kept  in  con- 
tact with  the  index  finger  by  a steel  spring  formed  of  several  short 
pieces  of  watch-spring  superposed.  The  arm  is  held  on  the  stump  by 
two  lateral  metallic  straps,  extending  along  each  side  of  the  arm,  and 
connected  above  by  two  padded  straps. 

When  the  arm  is  in  use,  by  giving  proper  tension  to  the  traction 
cord  the  person  has  only  to  extend  the  stump  to  expand  the  fingers 
in  grasping  objects;  the  traction-cord  acts  upon  the  upper  lever, 
which  draws  directly  upon  the  extending  cord  of  the  thumb,  and  at 
the  same  time  forces  the  radial  end  of  the  lower  lever  with  the  metal- 


234  APPARATUS  FOR  REMEDYING  THE  LOSS  OF  PARTS. 


lie  rod  above-mentioned  downwards,  and  as  all  the  fingers  are  solidly 
connected  with  the  middle  finger,  to  which  the  rod  is  attached,  they 
must  be  extended.  If  the  stump  of  the  forearm  is  now  flexed,  the 
traction  cord  ceases  to  act  upon  the  levers,  the  thumb  and  index  finger 
will  be  approximated  by  the  springs  connected  with  them,  and  seize 
the  object,  whatever  it  may  be,  between  them. 

In  this  manner  a person  will  be  enabled  to  pick  up  a pockethand- 
kerchief,  or  hat,  a paper,  or  other  such  objects ; a pen  may  also  be 
held  in  the  hand,  and  with  a little  practice  the  person  may  write  very 
well  with  it.  A basket  or  satchel,  or  anything  having  a similarly 
arranged  handle,  may  be  carried  upon  the  hook  formed  by  the  little 
finger. 

Mr.  Kolbe,  of  this  city,  is  also  the  inventor  of  a meritorious  artifi- 
cial arm,  the  mechanism  of  motion  of  the  fingers  consisting  of  metallic 
levers  acted  upon  by  a single  cord  of  traction ; the  fingers  have  the 
same  number  of  joints  as  are  found  in  the  natural  hand.  It  should  be 
observed,  however,  in  regard  to  this  point — the  introduction  of  nume- 
rous joints  in  the  fingers — that  it  adds  little,  if  any,  to  the  utility  of 
the  hand,  while,  at  the  same  time,  it  possesses  the  very  decided  draw- 
back of  requiring  a larger  number  of  levers,  which  add  much  to  the 
expense  and  complexity  of  the  mechanism.  To  overcome  the  increased 
amount  of  friction  of  the  levers,  greater  power  must  also  be  applied 
upon  the  traction  cords,  which  in  limbs  fitted  to  short  arm  stumps 
very  much  impairs  their  utility  and  range  of  motion. 

We  have  now  considered  the  more  complex  and  expensive  artificial 
arms  requiring  the  greatest  amount  of  mechanical  and  artistical  ability 
in  their  fabrication,  and  -which  must  of  necessity  be  almost,  if  not 
entirely,  within  the  reach  of  the  wealthier  classes  alone.  It  remains 
for  us  to  consider  briefly  those  prosthetic  contrivances  which  are 
simple  in  construction,  and  within  the  means 
of  all  persons. 

In  case  of  disarticulation  at  the  shoulder- 
joint,  an  artificial  limb  can  be  constructed  and 
affixed  to  a shoulder  cap  or  a corset;  being 
modelled  in  exact  imitation  of  the  remaining 
natural  limb,  it  will  restore  symmetry  to  a per- 
son’s appearance,  but  little  natural  motion  can  be 
obtained.  The  limb  should  not  be  straight,  but 
possess  that  graceful  curve,  Fig.  150,  which  the 
natural  arm  assumes,  hanging  in  its  own  as- 
sumed position  by  his  side,  when  a person 
stands  erect.  For  the  poorer  classes  who  de- 
pend upon  mechanical  pursuits  for  a livelihood, 
an  arm  without  a hand,  and  terminating  at  the 
wrist  with  a metallic  screw  plate  to  which  many 
useful  implements  may  be  affixed,  will  be  the 
most  useful.  For  example,  a porter  or  messen- 
ger might  find  great  assistance  in  a hook  for  carrying  bundles,  a basket, 
or  any  such  articles.  Should  the  amputation  have  been  performed 
between  the  shoulder  and  elbow,  a stump  will  be  left  which  will  per- 


150. 


The  common  artificial  arm. 


APPARATUS  FOR  THE  UPPER  EXTREMITIES. 


235 


mit  the  artificial  member  to  be  attached  much  more  easily  by  shoulder 
and  thoracic  bands,  and  at  the  same  time  be  much  more  comfortable 
to  the  wearer,  who  will  then  be  able  to  dispense  with  that  part  of  the 
mechanism  required  upon  the  chest,  and  to  which  an  arm  adapted  to 
a disarticulation  at  the  shoulder  must  be  affixed. 

Where  the  amputation  is  made  through  the  forearm  and  a freely 
mobile  stump  obtained,  greater  latitude  of  motion  can  be  impressed 
upon  the  artificial  member,  and  the  varied  occupations  in  which  a 
person  may  engage,  in  consequence,  will  enable  the  physician  to  direct 
many  useful  instruments  to  be  affixed  to  the  screw-plate.  Such,  for 
example,  as  a knife  or  fork,  a three-pronged  hook  for  driving,  as  seen 
in  Fig.  151,  or  indeed  any  implement  that  can  be  used  under  these 
circumstances,  and  which  may  be  demanded  by  special  trades  or 
callings ; even  a pen  may  be  used  when  held  by  a tube  supported 
upon  a stem  projecting  from  the  plate,  or  a pair  of  forceps.  These 
mechanical  contrivances  may  also  be  fastened  to  the  palm  of  the 
hand,  should  it  be  desired  to  have  one  in  connection  with  the  arm. 

Fig.  151. 


Ann  with  driving  kook  attached. 

The  sheath  must  be  neatly  moulded  to  the  forearm,  and  may  be 
held  in  place,  if  there  is  sufficient  length  of  leverage,  by  two  lateral 
bands  connecting  its  upper  border  with  a band  surrounding  the 
arm;  or  if  the  amputation  is  nearer  the  elbow,  two  jointed  lateral 
stems,  connected  above  with  a padded  metallic  band  embracing  the 
arm,  will  afford  more  security. 

A still  more  natural  appearance  and  a greater  range  of  useful  move- 
ments may  be  obtained  by  giving  to  the  hand  movements  somewhat 
approximating  those  possessed  by  the  natural  wrist  and  fingers.  A 
glance  at  the  anatomical  arrangement  of  the  natural  constituents  of 
the  wrist-joint  will  render  it  evident  that  the  imitation  must  necessarily 
be  rude  and  imperfect ; yet  this  can  be  accomplished  to  such  a degree 
las  to  render  the  artificial  movements  of  considerable  assistance.  Strictly 
the  wrist  possesses  but  four  movements : adduction,  abduction,  flexion, 
and  extension;  and  the  apparent  circumduction  possessed  by  it  is  ac- 
complished from  the  facility  with  which  the  hand  passes  from  a position 
of  flexion  or  extension  to  those  of  abduction  and  adduction ; there  is  no 
rotative  motion  in  this  joint.  The  normal  motion  possessed  by  the 
thumb-joint  is  flexion  and  extension  with  a very  slight  lateral  move- 
ment; the  thumb  derives  its  extended  and  varied  range  of  motion 


286  APPARATUS  FOR  REMEDYING  THE  LOSS  OF  PARTS. 

principally  from  the  first  carpo-metacarpal  articulation,  which  is  really 
in  some  degree  susceptible  of  all  the  motion  of  an  enarthrodial  joint. 

The  mechanical  provision  in  artificial  arms  permitting  rotative 
motion  in  the  wrist  is  extremely  simple,  consisting  of  a keyhole  plug 
fastened  to  the  wrist-plate  and  fitting  a corresponding  keyhole  upon 
the  arm-plate ; the  range  of  motion  of  the  hand  upon  the  forearm 
being  regulated  by  a spring  in  the  lower  part  of  the  latter  catching  in 
a series  of  indentations  upon  the  wrist-plate.  Thus  any  desired  rota- 
tive position  may  be  impressed  upon  the  hand  at  the  will  of  the  per- 
son. Extension  and  flexion  of  the  hand  may  be  accomplished  with  a 
cup-like  depression  in  the  wrist-plate,  with  which  a spherical  knob 
upon  the  arm -plate  articulates,  and  is  secured  in  accurate  contact  with 
it  by  a little  pin  connecting  its  apex  with  the  bottom  of  the  concavity. 

No  construction  yet  invented  is  even  a fair  imitation  of  the  natural 
movements  of  the  thumb,  which  are  numerous,  varied,  and  important, 
and  in  their  perfection  are  confined  to  man  alone.  Other  animals,  it 
is  true,  enjoy  some  share  in  them,  yet  they  cannot  approximate  the 
tips  of  the  fingers  and  thumb  with  that  accuracy  and  firmness  essential 
to  the  full  performance  of  many  digital  operations  executed  by  man. 
It  is  provided  with  larger  muscles  and  a greater  number  than  any  of 
the  other  fingers.  The  muscles  act  upon  its  carpo-metacarpal  and 
two  digital  joints  in  divers  manners  and  directions,  and  thus  it  can  be 
readily  understood  how  difficult  it  is,  with  springs  and  cords,  to  pro- 
duce even  a partial  similitude  to  the  natural  actions.  Indeed,  little 
more  than  a spring  can  be  placed  in  the  centre  of  the  thumb  to  retain 
it  continuously  in  contact  with  the  ends  of  the  fingers : so  that  any 
object  placed  in  between  them  will  be  grasped  and  held  in  pretty 
much  the  same  manner  as  it  would  by  a common  spring  clothes-pin. 

Though  these  mechanical  arrangements  in  the  wrist  and  thumb- 
joints  are  exceedingly  rude  and  imperfect  when  compared  with  the 
natural  organ  for  the  movements  of  these  parts,  they  yet  contribute 
somewhat  both  to  the  natural  appearance  of  an  artificial  limb  and  its 
utility. 

The  efforts  of  surgeons  latterly  in  amputating  through  the  various 
joints  of  the  hand,  preserving  just  as  much  of  that  part  as  the  nature 
of  the  injury  will  permit,  has  resulted  in  some  glorious  results  for 
conservative  surgery.  Even  a single  finger  will  do  good  service,  or 
a part  of  a finger,  when  it  is  practicable  to  preserve  this  much,  will 
contribute  to  a patient’s  welfare.  Many  digital  operations  may  be 
satisfactorily  performed  by  the  thumb  and  index  or  any  one  of  the 
other  fingers,  so  that  the  conservation  of  the  thumb  and  a digital  oppo- 
nent is  of  so  great  importance  to  a patient  that  it  should  always 
engage  the  surgeon’s  earnest  attention  while  performing  these  opera- 
tions about  the  joints  of  the  hand. 

Little  more  can  be  done  by  prosthesis  in  such  cases  than  to  restore 
the  symmetry  of  the  part,  which  may  be  satisfactorily  accomplished 
bv  moulding  a sheath  of  leather  or  other  suitable  material  to  the 
stump  of  hand  to  which  the  missing  member  may  be  readily  affixed. 
The  deformity  arising  from  the  loss  of  a single  finger  can  be  made  to 
disappear  by  having  a glove  of  an  appropriate  size  to  fit  the  wearer, 

\ 


APPARATUS  FOR  THE  LOWER  EXTREMITIES. 


237 


and  to  which,  a false  finger  corresponding  to  the  one  lost  may  be 
attached. 

Art  still  further  endeavors  to  bring  nearer  to  perfection  these  arti- 
ficial substitutes  by  conferring  upon  them  some  degree  of  that  softness 
and  elastic  feeling  of  the  natural  member.  This  has  been  to  some 
extent  accomplished  by  means  of  a coating  of  India-rubber,  which, 
however,  does  not  possess  that  smoothness  and  warmth  to  complete 
the  deception  of  the  sense  of  touch. 

From  the  foregoing  consideration  it  will  be  seen  that  it  is  not  an 
indifferent  matter  as  to  the  place  at  which  the  amputation  has  been 
effected,  as  regards  the  ease  with  which  an  artificial  limb  may  be 
attached,  or  the  amount  of  utility  such  a mechanism  possesses.  It  has 
been  seen  that,  when  disarticulation  has  been  performed  at  the  shoulder 
or  the  amputation  performed  near  to  it,  the  arm  must  of  necessity  be 
attached  to  some  contrivance  upon  the  chest,  and  thus  complicate  the 
mechanism  and  inconvenience  the  patient;  at  the  same  time  there  is 
no  stump  to  exercise  a leverage  upon  the  arm  and  thus  extend  its 
range  of  motion. 

Of  amputation  between  the  arm  and  elbow,  the  point  most  con- 
venient for  the  adaptation  of  a prosthetic  substitute  is  that  at  the 
junction  of  the  middle  with  the  lower  third,  though  with  care  an  arm 
may  be  made  for  a stump  of  any  length.  Perhaps  the  mechanical 
difficulties  culminate  in  an  amputation  through  the  elbow-joint,  which 
will  give  a large  and  broad  stump  liable  to  be  pressed  upon  injuriously 
by  the  lower  part  of  the  arm  sheath,  and  also  to  interfere  with  the 
mechanism  of  the  elbow. 

Two-thirds  of  the  length  of  the  forearm  will  give  a gently  tapering 
stump  to  which  an  arm  may  be  fitted  with  ease,  and  possess  as  great 
a range  of  movements  by  the  action  of  the  stump  as  can  be  attained 
by  any  other  length.  More  stump  than  this  will  embarrass  the 
motions  of  the  wrist-joint,  and  occasionally  be  the  source  of  annoy- 
ance to  the  patient  by  pressure  of  the  sheath  upon  its  extremity. 

SECTION  IY. 

APPARATUS  FOR  REMEDYING  DEFICIENCIES  OF  THE  LOWER  EXTREMITIES. 

Deficiency  of  the  Leg. — The  necessity  for  an  artificial  substitute 
after  the  loss  of  a lower  extremity  is  far  greater  than  for  that  of  an 
arm ; the  loss  is  more  seriously  felt  when  a person  is  dependent  upon 
his  avocation  for  maintenance,  and  is  compelled  to  make  active  exer- 
tion in  the  execution  of  the  duties  it  imposes  upon  him.  Should  the 
free  use  of  both  hands  be  necessary,  he  will  also  find  the  amount  of 
assistance  they  afford  materially  diminished  if  compelled  to  hobble 
; about  upon  a crutch,  which  imperiously  calls  for  the  service  of  one  of 
his  hands.  So  we  might,  in  such  a case,  really  say  that  the  loss  of  a 
leg  also  implies  that  of  an  arm,  which,  hitherto  peculiarly  devoted  to 
the  performance  of  varied  and  important  actions  executed  by  this 
organ,  is  now  turned  away  into  a new  channel,  and  assumes  a partici- 
pation in  the  office  of  progression.  The  ordinary  crutch  was,  of 
course,  the  first  kind  of  mechanical  assistance  that  would  have  natu- 


238  APPARATUS  FOR  REMEDYING  THE  LOSS  OF  PARTS. 

rally  suggested  itself  to  do  away  with  the  accompanying  inconveni- 
ences, and  incapacity  of  moving  about,  yet  at  a very  early  period 
artificial  legs  were  used,  and  this  suggests  the  superior  importance  in 
which  the  construction  of  legs  over  arms  was  held  by  the  ancients,  as 
they  have  transmitted  absolutely  nothing  concerning  the  preparation 
of  the  latter,  as  has  already  been  stated  in  the  previous  section,  while 
several  authors  describe  artificial  legs. 

If  we  first  consider  the  mechanical  circumstances  under  which  a 
natural  leg  is  placed,  we  shall  be  better  able  to  appreciate  the  ad- 
vantages and  disadvantages  of  the  various  kinds  of  prosthetic  appa- 
ratus destined  for  the  lower  extremity,  and  the  conditions  which  they 
must  fulfil  in  order  to  meet  the  requirements  and  necessities  of  a 
person  compelled  to  employ  them  in  the  act  of  progression.  The 
human  body  in  health,  standing  erect  at  ease,  has  the  heels  approxi- 
mated and  the  toes  turned  outwards,  so  that  the  axis  of  the  foot  cuts 
the  line  of  direction  of  progression  at  an  oblique  angle,  and  has  its 
various  parts  distributed  in  equilibrium  about  a central  axis  or  line  A D, 
of  gravity,  which,  starting  from  the  vertex  of  the  head,  falls  between 
the  occipital  condyles,  passes  thence  downwards  to  the  tip  of  the  coc- 
cyx, and  terminates  at  a point  upon  the  plane  upon  which  the  person 
stands,  midway  between  the  two  heels.  This  line  of  gravity  remains 
unchanged  as  long  as  the  equilibrium  is  undisturbed  ; but  the  moment 
the  person  changes  his  position,  as  in  walking,  the  equilibrium  is 
altered,  and  necessarily  the  line  of  gravity,  which  is  shifted  alternately, 
as  the  weight  of  the  body  is  borne  first  upon  one  leg 
and  then  upon  the  other,  to  positions  represented 
by  the  dotted  lines  A E,  A c (Fig.  152).  In  this 
manner,  while  the  equilibrium  of  the  body  is  estab- 
lished around  an  axis  passing  from  the  vertex 
through  the  ischium  and  coinciding  with  the  axis 
of  one  of  the  lower  extremities  to  the  sole  of  the 
foot,  the  opposite  extremity  swings  forward  after 
the  pelvis  is  thrown  forward  by  the  extension  of  the 
limb  to  that  position  necessary  in  taking  a step,  by 
the  force  of  gravity  alone ; so  that  really  little  or  no 
muscular  force  is  expended  except  that  consumed  in 
flexing  the  leg  to  an  extent  requisite  for  raising  the 
foot  from  the  ground. 

The  experiments  of  the  TV  ebers  conclusively  prove 
that  the  legs  of  a dead  body,  held  in  an  upright 
position  and  moved  forwards,  may  be  made  to  exe- 
cute the  movements  of  those  of  a living  person  in 
progression,  if  a substitutive  force  for  that  exerted 
by  the  muscles  in  lifting  the  feet  from  the  ground 
be  employed. 

Of  the  four  joints  of  the  lower  extremity,  the  hip, 
knee,  ankle,  and  first  metatarsal  phalangeal  articula- 
tion, which  in  an  especial  manner  contribute  to  the  ease  and  efficiency 
of  walking,  the  ankle-joint,  including  the  connections  between  the  tarsal 
bones,  deserves  especial  attention,  as  it  is  the  difficulty  of  imitating 


Fig.  152. 


APPARATUS  F-OR  THE  LOWER  EXTREMITIES.  239 


their  movements  which  has  hitherto  been  in  the  way  of  the  surgeon  in 
devising  an  artificial  leg  possessing  life-like  actions.  The  tibio- 
astragalal  articulation  permits  flexion  and  extension  with  a slight 
degree  of  rotation,  while  the  articulations  between  the  tarsal  bones 
themselves  confer  most  of  the  power  of  abduction  and  adduction  and 
rotation  enjoyed  by  the  foot.  With  this  extended  range  of  motion  at 
this  point,  the  muscles  of  the  lower  extremity  bring  with  ease  the 
body  in  equilibrium  about  the  line  of  gravity  of  the  limb,  and  there- 
fore this  joint  must  contribute  largely  to  rapid  and  graceful  walking. 
Were  this  otherwise,  as  indeed  sometimes  happens  in  diseases  of  the 
bones  of  the  foot  and  consequent  anchylosis  of  the  joints,  and  the 
movements  of  the  ankle  restricted  to  simple  flexion  and  extension,  for 
instance,  the  muscles  could  not  readily  balance  the  body  when  sup- 
ported alternately  upon  one  leg  and  the  other  in  walking,  and  the  gait 
would  then  be  awkward,  slow,  and  shuffling.  The  weight  of  the  body, 
when  a person  stands  upon  one  foot,  is  sustained  in  the  direction  of  a 
line  running  through  the  femur,  acetabulum,  tibia,  and  the  arch  of  the 
foot,  by  these  osseous  pillars  placed  in  the  interior  of  the  lower  ex- 
tremity. The  centres  of  the  knee  and  ankle-joints  are  placed  some- 
what behind  this  line,  so  that  when  the  limb  is  straight  the  weight  of 
the  body  adds  to  their  strength,  and  relieves  the  muscles  greatly  in 
sustaining  the  body  erect. 

With  these  mechanical  conditions  under  which  a natural  limb  is 
placed  in  supporting  the  weight  of  the  body,  either  at  rest  or  in  the 
act  of  walking,  impressed  upon  the  mind,  we  are  prepared  to  under- 
stand how  far  the  various  artificial  substitutes  do  and  can  fulfil  their 
purposes  when  the  loss  of  a limb  compels  a person  to  seek  their 
assistance.  Those  persons  who  have  paid  much  attention  to  this 
subject,  and  devised  such  apparatuses,  have  been  more  or  less  suc- 
cessful in  proportion  to  their  knowledge  and  appreciation  of  the  ana- 
tomical structure  and  physiological  actions  of  the  natural  limb. 

Commencing  with  the  foot,  we  shall  see  that  the  prosthetic  apparatus 
for  it,  although  contributing  somewhat  to  progres- 
sion, are  more  especially  employed  to  correct  de- 
formity. The  class  of  operations  requiring  them  are 
' amputations  and  resections:  among  the  former  are 
ranged  Syme’s,  Chopart’s,  Hays’  and  PerigofTs  ope- 
rations ; and  among  the  latter  the  removal  of  the 
astragalus  or  os  calcis  separately,  or  both  together,  as 
in  the  process  of  Mr.  T.  Wakely,  Jr.  When  there 
is  a sound  and  well-formed  stump  obtained  by  any 
of  these  processes,  which  will  sustain  the  weight  of 
the  body  without  pain,  the  walking  of  a person  so 
maimed  may  be  materially  assisted  by  the  shoe 
represented  in  Fig.  153,  which  has  a sole  of  suffi- 
cient thickness  to  make  up  any  difference  in  the 
length  of  the  two  limbs,  and  supports  the  parts  by 
lacing  high  up  upon  the  ankle. 

The  addition  of  an  artificial  foot  is  a question 
of  considerably  more  mechanical  difficulty,  from  °0 a ataakiC aU<m 


Fig.  153. 


240  APPARATUS  FOR  REMEDYING  THE  LOSS  OF  PARTS. 

the  fact  that  there  exists  great  difficulty  in  fastening  the  shoe  to  the 
stump  in  such  a manner  that  it  will  not  press  upon  its  anterior  sur- 
face, which  must  occur  if  the  artificial  foot  is  placed  against  it,  every 
time  the  leg  bends  forwards  in  locomotion.  To  prevent  this  upward 
action  of  the  artificial  foot,  it  is  simply  necessary  to  provide  a metallic 
sole,  upon  the  upper  surface  of  which  there  is  a padded  socket  to  receive 
the  stump  and  part  of  a foot,  in  exact  imitation  of  the  lost  portion  of  the 

natural  organ,  and  having  a toe-joint. 
Its  posterior  extremity  is  deeply 
grooved  to  fit  accurately  the  anterior 
surface  of  the  stump,  to  which  it  is 
fastened  by  straps.  To  the  metallic 
plate  there  are  fastened  two  steel 
rods,  running  up  the  leg  to  the 
knee,  one  upon  each  side,  provided 
with  bands,  &c.  to  secure  the  ap- 
paratus in  place ; corresponding  to 
the  ankle-joint,  there  is  placed  a 
stop-joint,  which  prevents  the  ante- 
rior part  of  the  foot  being  flexed  at 
more  than  a right  angle  with  the 
leg.  When  the  artificial  substitute 
is  securely  connected  with  the  leg, 
and  the  patient  attempts  to  walk,  as  the  heel  is  lifted  the  stop-joint 
sustains  the  foot  at  right  angles  to  the  leg  until  the  pressure  comes 
upon  the  toe-joint,  which  yields  immediately,  and  thus  imparts  a 
natural  motion  to  the  step  without  lifting  the  front  of  the  foot  suffi- 
ciently to  throw  its  upper  and  back  part  against  the  stump. 

If  the  toes  or  anterior  part  of  the  metatarsus  are  simply  removed, 
an  ordinary  shoe,  with  its  anterior  portion  properly  padded,  will  serve 
the  purpose  of  concealing  the  deformity.  The  same  plan  may  answer 
also  after  Key’s  operation  ; should  it  not,  however,  in  consequence  of 
the  tilting  of  the  artificial  part  against  the  end  of  the  stump,  the  pre- 
vious plan  must  be  adopted. 

After  the  resections  above  mentioned,  the  only  prosthetic  apparatus 
required  will  be  a common  shoe  with  a sufficiently  high  heel  to  make 
up  the  difference  of  length  between  the  injured  and  sound  limbs. 

In  the  foregoing  cases  the  weight  of  the  body  is  borne  upon  the 
stump ; but  when  the  amputation  is  performed  between  the  knee  and 
ankle,  this  cannot  be  done,  however  skilfully  the  operation  may  have 
been  executed,  or  however  successful  it  may  have  been  in  securing  a 
well-covered  and  fleshy  stump.  In  any  case,  the  weight  of  the  body 
would  soon  cause  the  soft  parts  to  be  absorbed,  and  the  end  of  the 
bone  to  protrude.  It  scarcely  matters  much  how  great  a mass  of 
muscular  substance  may  be  placed  over  the  bone,  for  in  the  course  of 
a few  months  the  tissue  will  become  atrophied  and  converted  into  a 
dense  cellulo-fibrous  mass,  and  the  end  of  the  bone  rounded  off  and 
conical.  As  this  is  the  natural  method  observed  in  the  subsequent 
modelling  of  the  extremity  of  an  amputated  limb,  it  would  seem 
that  too  much  stress  has  been  placed  upon  the  importance  and  supe- 


Fig.  154. 


Apparatus  for  amputation  through  the  foot. 


APPARATUS  FOR  THE  LOWER  EXTREMITIES. 


241 


Fig.  155. 


The  common  socket-leg 


rioritj  of  certain  processes  over  others  in  securing  the  best  stump  for 
an  artificial  leg ; when  the  truth  really  is  that  no  greater  thickness  of 
tissue  will  be  found  over  the  bone  after  the  lapse  of  a twelvemonth, 
in  operations  with  voluminous  muscular  flaps,  than 
after  a circular  operation  with  flaps  of  skin  and 
cellular  tissue.  In  either  case,  if  the  stump  is  well 
rounded  and  sound,  it  will  suffer  with  impunity  the 
amount  of  strain  brought  to  bear  upon  it  in  em- 
ploying an  artificial  leg.  As  stated  above,  the 
natural  limb  has  but  one  point  of  bearing,  that  is, 
in  its  axis  or  line  of  gravity,  but  this  cannot  be 
imitated  in  adapting  a prosthetic  apparatus,  from 
the  stump  being  intolerant  of  pressure;  so  that  the 
surgeon  is  compelled  to  make  a point  of  bearing  of 
the  entire  outer  surface  of  the  stump,  by  inclosing 
it  in  an  accurately  fitting  sheath  of  stout  leather  or 
willow.  This  diffusion  of  pressure  over  as  great 
an  extent  of  surface  as  possible  should  always  be 
kept  in  view  in  making  artificial  socket  limbs  of 
any  description,  for  it  is  manifest  that  the  local 
effects  of  pressure  or  force  of  any  kind  must  di- 
minish in  the  ratio  of  its  diffusion  over  the  surface 
upon  which  it  acts.  The  common  socket-leg  (Fig. 

155)  is  constructed  in  this  manner,  with  an  accu- 
rately-fitting wooden  sheath,  into  the  bottom  of 
which  a pin  of  the  same  material  is  inserted,  to 
make  up  the  distance  between  the  stump  and  the  ground.  The  leg 
is  prevented  from  falling  off  by  the  lateral  straps  connected  with  a 
leathern  thigh-band.  A still  more  seemly  artificial  leg  (Fig.  156)  is 
manufactured,  which,  instead  of  the  pin 
| attached  to  a socket,  has  a foot  with 
movable  ankle  and  toe  joints,  and  is 
fastened  in  the  same  manner  as  the 
socket-leg.  This  point  will,  however, 
jj  depend  much  upon  the  length  and  con- 
dition of  the  stump,  which,  if  but  three 
or  four  inches  long,  will  require  two 
lateral  metallic  stems  joined  at  the  knee, 
and  fastened  above  to  a metallic  thigh- 
band,  that  the  stump  may  not  be  drawn 
from  the  socket  while  the  person  exe- 
cutes the  act  of  locomotion.  Equally 
as  great  an  evil  is  a too  lengthy  stump, 

;the  end  of  which  is  constantly  liable  to 
rub  against  the  inner  surface  of  the 
sheath,  and  cause  the  wearer  of  the  leg 
constant  pain  or  uneasiness  while  mov- 
ing about.  This  rubbing  often  occurs  upon  the  anterior  surface  of 
the  tibia,  and  may  demand  that  that  part  of  the  wall  of  the  socket 
corresponding  to  it  be  removed,  so  that  the  end  of  the  stump  may 


Fig.  156. 


Artificial  leg  for  amputation  below  tlie 
knee. 


242  APPARATUS  FOR  REMEDYING  THE  LOSS  OF  PARTS. 


have  unrestrained  play.  Again,  where  the  stump  is  badly  healed 
and  tender,  and  cannot  bear  the  pressure  of  the  socket,  the  artificial  leg 

must  be  still  further  modified,  so 


Fig.  157. 


Apparatus  for  extending  a contracted  stump. 


as  to  receive  the  weight  of  the 
body  upon  a leather  cap  fitting 
inside  of  the  socket  and  closely 
embracing  the  stump  as  high  up 
as  the  tubercle  of  the  tibia. 

It  sometimes  happens,  also,  from 
the  shortness  of  a stump,  or  other 
cause,  that  it  remains  after  the 
lapse  of  some  time  in  a perma- 
nently flexed  position,  requiring, 
before  any  of  the  above  forms  of 
prosthetic  apparatus  can  be  had 
recourse  to,  that  it  be  extended 
and  restored  to  some  degree  of 
mobility.  To  accomplish  this,  the 
simple  apparatus  seen  in  the  figure 
(Fig.  157)  may  be  employed;  it 
consists  of  two  lateral-jointed  metallic  rods,  connected  below  by  a 
metallic  gutter  fitted  to  the  posterior  surface  or  calf  of  the  leg,  and 
extending  above  the  knee.  A strong  cloth  band,  crossing  the  patella 
and  attached  to  the  two  rods  upon  either  side,  serves  the  purpose  of  a 
fulcrum.  The  extending  force  is  applied  to  the  upper  extremities  of 
the  bars  by  means  of  an  India-rubber  band  passing  between  them 
and  the  thigh. 

Auother  form  of  artificial  leg  (Fig.  158)  for  a stump  below  the  knee, 
is  the  common  wooden  pin  or  “ box  leg.”  It  consists  of  a wooden 
frame  widely  grooved  below  to  accommodate  the  knee, 
and  of  two  lateral  side  pieces;  the  external,  slightly 
curved  backwards,  reaches  from  the  knee  to  the  crest  of 
the  ilium,  and  the  internal,  half  way  up  the  thigh ; from 
the  bottom  of  the  socket  a pin  projects,  and  makes  up 
the  interval  between  the  knee  and  the  ground. 

The  apparatus  is  fastened  to  the  body  by  a strap 
passing  around  the  waist,  and  the  outer  and  upper  end 
of  the  side  piece ; to  give  the  leg  stability  and  insure 
firmness  in  stepping,  the  pin  must  be  mortised  squarely 
at  the  knee,  and  with  as  broad  a base  as  possible.  To 
prevent  the  projection  of  the  superior  extremity  of  the 
leg  backwards  when  the  person  sits  down,  a joint  may  be 
placed  upon  it  at  a point  corresponding  to  the  articula- 
tion of  the  hip. 

M.  de  Beaufoy  has  invented  a foot  for  the  wooden 
pin  worn  by  the  pensioners  at  the  Invalides  at  Paris. 
The  advantage  of  this  improvement,  says  Guthrie,  is 
“that  whereas  a common  wooden  pin  has  only  one 
point  of  support,  and  consequently  the  body  is  obliged  to  raise  itself 
so  as  to  describe  an  arc  of  which  the  end  of  the  wooden  pin  is  the 


The  “wooden 
pin.” 


APPAKATUS  FOR  THE  LOWER  EXTREMITIES.  243 

centre,  the  curved  foot  acts  like  a series  of  levers,  each  successive 
point  of  it  being  a fulcrum.” 

The  weight  of  the  body  with  this  leg  is  borne  upon  the  knee,  and 
■ is  transmitted  to  the  ground  in  the  normal  line  of  the  centre  of  gravity 
of  the  limb. 

For  amputations  of  the  thigh  we  will  not  find  as  great  a variety  of 
artificial  limbs,  from  the  circumstance  that  they  present  us  with  a 
stump  of  a pretty  uniform  character  as  to  length  and  shape ; yet  it  is 
here  that  we  find  the  greatest  efforts  of  mechanical  ingenuity  displayed, 
and  the  greatest  number  of  methods  by  which  the  mechanical  require- 
ments of  an  artificial  leg  are  fulfilled.  The  mechanical  conditions 
under  which  a natural  leg  is  placed  while  the  function  of  locomotion 
is  being  executed  have  already  been  briefly  alluded  to,  and  it  was 
stated,  then,  that  the  weight  of  the  body  in  changing  its  position  in 
walking  was  thrown  alternately  upon  one  and  the  other  leg,  and  sup- 
ported in  a line  of  gravity  running  through  the  acetabulum,  femur, 
and  bones  of  the  leg;  that  there  was  but  one  point  of  bearing,  and  that 
was  central ; that  the  muscles  were  chiefly  concerned  in  raising  the 
foot  from  the  ground,  and  that  the  gravitation  of  the  limb  carried  it 
forwards  to  its  destined  position. 

Prepared  with  these  facts,  we  can  now  inquire  how  these  conditions 
may  be  realized  in  a prosthetic  apparatus : — 

1st.  As  to  the  points  of  support  or  bearing:  We  cannot  mechani- 
cally restore  that  part  of  the  line  of  gravity  represented  in  the  natural 
limb  by  the  femur,  and  destroyed  with  the  removal  of  the  leg ; as 
■the  only  way  to  do  so  would  be  to  make  the  end  of  the  divided  bone 
a point  of  pressure  by  establishing  again  the  same  length  of  bony 
column  which  supports  the  body  naturally  (which,  as  we  have  already 
shown,  is  impossible).  The  only  way,  then,  is  to  inclose  the  stump  in 
a sheath,  technically  called  “a  bucket,”  to  diffuse  the  pressure  over  its 
surface  to  as  great  an  extent  as  possible,  and  thus  to  transmit  the 
weight  of  the  body  to  the  ground,  not  through  a central  axis  of  sup- 
port, but  by  a circumferential  support,  that  is,  by  the  walls  of  the 
bucket;  which  is  just  the  reverse  of  the  natural  condition  of  things, 
but  an  imposed  necessity.  Were  there  a projecting  point  about  this 
central  axis  capable  of  bearing  pressure,  and  against  which  the  upper 
edge  of  the  bucket  might  rest  in  supporting  the  body,  the  result  would 
be  much  more  satisfactory  than  any  we  now  obtain  by  pressure  upon 
the  surface  of  the  thigh  stump.  It  has  been  suggested  that  the  ischium, 
which  lies  posterior  to  this  line,  might  serve  as  a circumferential  point 
of  bearing;  and  with  this  view  the  upper  edge  of  the  bucket  of  some 
artificial  legs  ascends  to  it,  and  the  plan  answers  exceedingly  well. 

2d.  The  provisions  for  the  imitation  of  the  natural  action  of  the  joints 
,have  until  lately  been  very  unsatisfactory;  and  it  was  not  until  the  in- 
vention of  Dr.  Bly’s  leg  that  little  was  left  to  be  desired  in  this  direction. 
An  examination  of  the  structure  of  the  knee  and  ankle-joints  teaches 
us  that  their  centres  lie  a little  in  the  rear  of  the  line  of  gravity  of  the 
limb,  estimated  to  be  a half  an  inch  for  the  knee  and  three-quarters  of 
an  inch  for  the  ankle,  so  that,  when  the  limb  is  straight,  the  greater  the 
weight  transmitted  to  them  the  more  firm  they  are.  So  in  an  artificial 


244  APPARATUS  FOR  REMEDYING  THE  LOSS  OF  PARTS. 

limb,  the  articular  centres  or  bolts  should  be  placed  in  the  rear  of  this 
line  the  same  distance,  that  when  the  person  rests  the  weight  of  his 
body  upon  it,  the  joints  will  afford  a firm  and  secure  support,  and  be 
reinforced  just  in  proportion  to  that  weight. 

3d.  The  varied  actions  of  the  muscles  of  a natural  limb  in  the  exe- 
cution of  all  their  functions  cannot  be  fully  imitated  in  any  artificial 
mechanism,  but  those  chiefly  active  in  locomotion  may  be  to  a reason- 
able practical  extent.  As  to  the  knee-joint,  as  the  limb  swings  forward 
by  gravity  and  extends  the  leg,  really  no  mechanical  contrivance  for 
this  purpose  is  at  all  required,  but  with  the  ankle  it  is  quite  otherwise:  ; 
here  some  provision  must  be  made  for  the  flexion  and  extension  of  the 
foot,  else  in  walking  the  toe  would  either  be  constantly  catching  against 
every  uneven  spot  or  projecting  point  upon  the  ground,  or  approaching 
the  front  of  the  leg,  the  person  would  walk  upon  the  heel  alone,  if  the 
weight  of  the  body  did  not  bring  the  toe  down,  as  it  would  in  the 
latter  case,  with  a heavy  stroke. 

The  foot  must  be  then  secured  at  right  angles  to  the  leg,  in  such  a 
manner  that,  after  being  either  flexed  or  extended,  it  will  spontaneously  . 
and  promptly  return  to  its  original  position  when  the  force  is  removed. 
This  can  be  accomplished  in  several  manners,  with  elastic  cords,  spiral 
springs,  or  gut  cords  fastened  to  an  elastic  metal  slip  placed  in  the  sole 
of  the  foot.  India-rubber  is  an  exceedingly  valuable  material  in  the 
construction  of  artificial  limbs,  and  is  employed  to  imitate  the  action  of 
muscular  fibres,  from  its  capacity  of  contracting  promptly  after  being 
stretched ; but  after  being  used  some  time,  it  loses  this  indispensable 
property  to  a greater  or  less  extent,  and  is  then  apt  to  break.  Dr.  Bly 
happily  overcame  this  objection  by  availing  himself  of  the  expansive 
power  of  railroad  car-spring  rubber,  after  compression,  in  which  manner 
it  cannot  be  injured,  however  much  it  may  be  used.  Its  application 
will  be  seen  hereafter. 

Spiral  springs  are  arranged  in  the  ankle  in  the  manner  seen  in  the 
figure  (159),  one  in  front  of  the  instep  and  another  in  the  position  of 


the  tendo-Achillis.  Although  possessing  the  valuable  properties  of 
exercising  expansive  force  when  compressed,  and  contractile  force  when 
extended,  they  are  inferior  to  the  rubber  springs  used  in  the  Bly  leg. 


Fig.  159. 


Diagram  showing  the  mode  of  arranging  spiral  springs  in  the  ankle  and  their  action. 


APPARATUS  FOR  THE  LOWER  EXTREMITIES. 


245 


•which  give  a more  uniform  and  natural  movement  to  the  limb ; they 
do  not  become  weak  by  use,  nor  yet  do  they  rust  or  produce  any 
roughness  or  creaking  noise. 

It  now  remains  for  us  to  consider  the  prosthetic  apparatus  at  pre- 
sent in  use,  and  see  how  the  above  detailed  mechanical  principles  are 
carried  out  in  their  construction.  The  simplest  of  the  artificial  legs 
is  that  composed  of  an  accurately  fitted  “bucket,”  the  upper  margin 
of  which  should  abut  against  the  ischium,  and  of  a wooden  pin  to  make 
up  the  distance  to  the  ground : it  is  fastened  to  the  person  of  the 
wearer  by  a strap  passing  around  the  waist.  A more  convenient  limb 
than  the  above  may  be  obtained  by  providing  it  with  a hinge  corre- 
sponding with  the  knee,  and  controlled  by  a spring  check-slide,  placed 
upon  the  inner  side  of  the  bucket,  so  as  to  catch  in  a ratchet  fastened 
ito  the  same  side  of  the  leg-piece.  This  arrangement  places  the  com- 
mand of  the  movements  of  the  knee-joint  under  the  control  of  the 
person  wearing  the  artificial  limb,  and  enables  him,  when  seated,  to  flex 
it,  so  that  the  pin  will  not  inconvenience  or  trip  persons  moving 
^around  him,  as  it  would  do  if  it  were  straight  and  stuck  out  in  front. 

The  two  preceding  limbs  are  simple  in  their  construction,  and  within 
■the  reach  of  the  poorer  classes,  who  are  debarred  from  the  use  of  the 
legs  now  to  be  described  in  consequence  of  their  high  price.  The  best 
of  these,  and  the  one  we  shall  describe  first,  is  that  of  Dr.  Bly,  of 
Rochester,  N.  Y.,  who  has  succeeded  in  producing  a mechanism  the 
movement  of  which  imitates  very  closely  those  of  the  natural  limb. 
It  is  adapted  to  an  amputation  above  or  below  the  knee,  and  it  is  par- 
ticularly where  this  joint  is  preserved  and  enjoys  its  normal  motion 
that  Bly’s  limb  possesses  a point  of  superior  merit  in  external  form. 
The  artificial  limbs  for  stumps  below  the  knee,  made  formerly,  were 
.attached  to  the  wearer’s  person  by  two  straight  lateral  steel  straps, 
jointed  at  this  articulation  ; the  angles  formed  by  these  metallic  joints 
must  project  when  the  limb  is  bent  at  right  angles,  and  raise  the  per- 
son’s clothes  in  such  a manner  as  to  give  the  part  an  unnatural,  bulky, 
and  square  appearance,  at  variance  with  the  normal  symmetry  of  the  leg. 
Dr.  Bly  has  overcome  this  objectionable  feature  perfectly  by  curving 
both  the  leg  and  thigh-straps  in  such  a manner  as  to  throw  their  point 
af  junction  further  to  the  rear,  on  a level  with  the  centre  of  the  knee- 
joint,  so  that  the  clothes  remain  smooth  when  the  knee  is  bent  in 
assuming  a sitting  posture. 

This  natural  symmetry  of  the  knee-joint  is  in  accord  with,  and  har- 
nonizes  with  the  perfection  of  form  conferred  upon  the  other  portions 
af  the  limb,  which,  to  bring  it  still  closer  in  appearance  to  nature,  is 
covered  with  a flesh-colored  enamel,  permitting  a free  use  of  water 
or  cleansing  and  refreshing  its  surface. 

Besides  these  details  of  external  form,  the  far  more  important  ques- 
tions of  the  mechanical  construction  and  motive  powers  of  the  joints 
rave  developed  the  ingenuity  of  Dr.  Bly,  and  prove  how  indispensable 
i competent  knowledge  of  Anatomy  and  Physiology  is,  to  enable  a 
aerson  to  design  and  prepare  any  apparatus  in  the  treatment  of  the 
liseases  and  deficiencies  of  the  human  body.  As  we  have  seen,  the 
eg  is  carried  forward  by  gravity,  when  the  foot  is  raised  from  the 


246  APPARATUS  FOR  REMEDYING  THE  LOSS  OF  PARTS. 

ground,  and  the  hip  corresponding  to  it  swings  forwards  in  an  arc 
with  its  centre  at  the  acetabulum  of  the  opposite  side,  so  that  in 
reality  there  is  no  need  of  any  motive  power  being  placed  in  the  knee- 
joint;  yet  in  the  construction  of  the  artificial  limb  under  consideration, 
some  provision  of  this  kind  is  made.  A spring  of  railroad-car  spring 
India-rubber  is  introduced,  which,  by  its  expansion  after  being  com- 
pressed by  flexing  the  leg,  urges  the  latter  forwards  in  taking  a step : and 
when  the  foot  comes  to  the  ground,  in  order  to  prevent  shock,  or  any 
irregular  action  of  the  knee-joint,  two  cords  are  arranged  to  check  its 
movements  in  imitation  of  the  crucial  ligaments  in  the  natural  articu- 
lation. The  bucket,  or  thigh -sheath,  articulates  with  the  leg  with  the 
usual  steel  bolt ; indeed  the  bolts  are  the  only  iron  used  at  all  in  any 
part  of  the  construction  of  the  limb,  which  confers  upon  it  the  im- 
portant quality  of  lightness,  and  a superiority  in  this  respect  over 
those  mechanisms  in  which  that  metal  enters.  The  friction  of  these 
metallic  joints  implies  more  or  less  wearing  of  iron,  and  must,  there- 
fore, necessarily  become  loose,  and  unless  repaired  by  bushing,  rattle  at 
every  step;  they  also  demand  the  free  use  of  the  oil-can  to  destroy  their 
unpleasant  and  annoying  clatter.  In  the  ankle-joint  the  case  is  dif- 
ferent; there  nature  provides  a number  of  muscles  and  a joint  of 
peculiar  construction  for  sustaining  the  leg  in  that  line  with  the  foot 
required  by  the  gravity  of  the  body,  and  for  accomplishing  the  action  of 
progression.  It  is  in  this  respect  and  the  form  of  the  ankle-joint  that 
the  Bly  leg  possesses  undeniable  superiority  over  all  others,  if  close 
imitation  of  the  arrangements  and  functions  of  the  natural  limb  will 
entitle  it  to  a superiority.  The  ankle-joint  naturally  possesses  four 
motions,  flexion,  extension,  abduction,  and  adduction,  which,  readily 
passing  from  one  to  another,  confer  a compound  motion  equivalent  to 
circumduction,  enjoyed  alone  by  the  enarthrodial  or  ball-and-socket 
joints.  The  indispensableness,  too,  of  this  sort  of  compound  motion  in 
the  ankle,  for  quick  and  easy  progression,  is  seen  when  we  observe  a 
person  Aval  king  gracefully  and  rapidly:  the  toes  naturally  turn  out- 
wards, and  the  foot  performs  a sort  of  oblique  antero-posterior  move- 
ment, which  could  not  be  accomplished  with  a ginglymoid  joint,  a form 
of  articulation  adopted  in  most  artificial  limbs,  except  that  of  Dr. 
Bly.  He  employs  a ball-and-socket  joint  for  the  ankle,  the  ball  being 
of  ivory  and  the  socket  of  vulcanite,  so  that  all  the  motious  observed 
in  the  natural  foot  may  be  effected  by  the  foot  of  his  artificial  limb. 
Further,  the  joint  does  not  wear,  nor  require  oiling,  or  bushing  to  keep 
it  tight,  but  may  be  used  for  years  unceasingly,  without  requiring  the 
outlay  of  any  more  money  than  the  original  cost  of  the  limb.  The 
foot  will  remain  flat  upon  the  ground,  should  the  leg  be  thrown  out  to 
brace  the  body  for  any  unusual  exertion  or  effort;  and  in  walking 
upon  the  side  of  a hill,  or  any  other  iuclined  or  uneven  surface,  the 
sole  of  the  foot  will  assume  a natural  position,  parallel  with  the  plane 
upon  which  it  rests. 

In  the  ginglymoid  ankle-joint  of  other  artificial  limbs,  this  oblique 
action  of  the  foot  in  locomotion  can  only  be  imitated  by  rolling  it 
laterally  ; and  Avhen  the  person  wearing  a leg  constructed  Avith  such  a 
joint  Avalks  upon  an  inclined  or  uneven  surface,  the  side  of  the  foot 


APPARATUS  FOR  THE  LOWER  EXTREMITIES. 


247 


alone  remains  in  contact  with,  it,  while  the  upper  edge  of  the  bucket 
must  be  in  consequence  thrown  forcibly  against  the  thigh,  much  to 
his  discomfort,  and  the  impairment  of  firmness  of  step. 

The  foot  in  Bly’s  leg  is  under  the  control  of  five  catgut  cords,  con- 
nected with  an  equal  number  of  India-rubber  springs;  these  being 
placed  beneath  movable  nuts,  connected  with  the  cords,  traction  of 
the  latter  compresses  the  India-rubber,  and  its  expansion  exerts  the 
moving  power  of  the  foot.  By  adjusting  the  nuts,  any  desirable 
tension  may  be  given  to  the  cords  to  suit  the  person’s  gait. 

The  toe-joint  is  also  furnished  with  an  India-rubber  spring  and 
catgut  cord. 

The  readiest  way  of  understanding  the  foregoing  description  of 
this  artificial  limb  is  to  examine  attentively  the  annexed  illustration. 
Fig.  160  shows  a section  of  a limb  for 
amputation  above  the  knee.  T is  the  bucket 
with  the  piece  D spanning  the  diameter  of 
its  lower  part,  and  to  which  a cord  and 
spring  are  affixed,  ascending  from  the  pos- 
terior part  of  the  leg  and  serving  the  pur- 
pose of  urging  the  leg  forwards  after  it  has 
been  bent  in  taking  a step.  L is  the  leg- 
piece  articulating  at  the  knee  with  the 
bucket  T,  and  having  a diaphragm  across 
its  middle  part  through  which*  the  catgut 
cord  c passes  to  be  secured  by  the  movable 
nuts  N,  between  which  and  the  diaphragm  the 
springs  S of  railroad-car  spring  India-rubber 
are  placed.  There  are  but  three  of  the  five 
gut  cords  shown  in  the  figure.  B is  the 
polished  ivory  ball  working  in  a concavity 
lined  with  vulcanite.  In  the  posterior  half 
of  the  foot  are  seen  the  lower  attachments 
of  the  gut  cords,  imitating  the  natural  ten- 
dons. In  the  forepart  of  the  foot,  A F,  the 
toe-spring  is  shown.  Fig.  160,  2,  shows  the 
position  the  foot  assumes  when  it  treads 
upon  a projecting  object. 

Mr.  Kolbe,  of  Philadelphia,  has  devised 
a leg  in  some  respects  superior  to  that  of 
Bly.  It  possesses  slight  lateral  motion  of 
the  ankle,  enough  to  relieve  the  strain  upon 
the  thigh-sheath  when  the  person  steps  upon 

an  irregular  or  an  inclined  surface,  while  at  Bly’s  artificial  leg. 

the  same  time  it  does  not  render  the  walk- 
ing unstable,  as  it  must  do  if  too  great  an  amount  of  motion  is  given 
to  the  ankle. 

The  external  finish  and  strength  of  the  limb  give  it  rank  with  the 
best  automatic  appliance  now  offered  for  the  patronage  of  the  maimed, 
and  one  great  recommendation  it  possesses  is,  that  it  may  be  adapted 
to  every  form  or  length  of  stump. 


248  APPARATUS  FOR  REMEDYING  THE  LOSS  OF  PARTS. 


Fig.  161. 


Its  mechanism  is  so  simple  that  the  wearer  of  the  limb  can  in 
general  be  his  own  repairer  should  any  portion  of  it  give  out  or  need 

overhauling,  and  this  is  no  small  advantage 
to  persons  residing  at  a distance  from  the 
manufacturer. 

The  annexed  cut  (Fig.  161)  shows  a verti- 
cal section  of  a limb  designed  for  an  ampu- 
tation of  the  thigh.  As  is  usual,  the  frame- 
work is  of  willow  wood,  which  is  selected 
for  its  tenacity,  strength,  fine  grain,  and  light- 
ness. The  thigh-piece  or  bucket  is  commonly 
lined  with  washed  leather,  fitting  the  thigh 
accurately  and  extending  up  to  the  ischium 
and  perineum,  which  sustain  a part  of  the 
weight  of  the  body;  the  balance  being  dif- 
fused over  the  outer  surface  of  the  thigh. 
Its  walls  are  opened  by  oblong  slits  or 
fenestrae,  which  permit  the  proper  amount 
of  ventilation  being  effected,  and,  at  the  same 
time,  allow  the  secretions  of  the  part  to  escape. 

The  thigh-piece  is  strongly  articulated  at 
the  knee  to  the  leg-piece  by  a steel  bolt, 
which  permits  antero-posterior  motion  only. 
From  the  inner  surface  of  the  lower  third  of 
the  bucket  a wooden  pin,  I K,  projects,  to 
which  are  attached  two  strong  cords  made  of 
twisted  linen  thread.  One  of  these,  I E,  being-  inserted  into  the  heel, 
represents  the  tendo-Achillis ; it  supports  the  weight  of  the  body  by 
preventing  the  foot  being  bent  at  any  greater  angle  than  a right  angle. 
The  other  cord,  K D,  is  inserted  into  the  middle  of  the  posterior  sur- 
face of  the  leg,  and  is  accessory  to  the  former, 
an  arrangement  by  which  the  limb  is  rendered 
so  exceedingly  strong  that  the  weight  of  the 
strongest  man  cannot  impair  its  stability.  The 
cord  marked  G G is  a spiral  spring  which  is 
intended  to  give  the  leg  a slight  impulse  for- 
wards in  taking  a step ; it  is  the  analogue  of 
the  extension  quadriceps  of  the  natural  limb. 
It  has  already  been  stated  that  this  is  useless, 
and  experience  p>roves  it,  in  that  most  persons 
after  becoming  somewhat  familiar  with  the 
motions  of  the  leg  throw  this  elastic  strap 
aside. 

Fig.  162  shows  the  mechanism  of  the  ankle- 
joint.  It  is  somewhat  peculiar,  combining  all 
the  strength  of  a ginglymoid  joint  with  lateral 
motion.  The  inferior  surface  of  the  leg  and 
the  corresponding  surface  of  the  foot  are  pro- 
vided each  with  a hemispherical  depression  which,  when  conjoined, 
form  a hollow  sphere ; in  the  interior  of  this  sphere  the  globular  en- 


Fig.  162. 


APPARATUS  FOR  THE  LOWER  EXTREMITIES. 


249 


largement  seated  at  the  centre  of  the  steel  ankle  holt  works,  the  extre- 
mities of  the  holt  passing  through  the  lateral  metal  straps  in  holes  a 
little  larger  than  their  diameter ; these  extremities  are  sustained  by 
i two  pieces  of  India-rubber,  which  permit  that  amount  of  lateral  motion 
desirable  in  the  ankle. 

F F,  in  Fig.  161,  indicate  the  position  of  a cord  attached  to  a hori- 
zontal metallic  spring  fastened  to  the  sole  of  the  foot  and  intended  to 
bring  the  foot  again  to  a rectangular  position  with  the  leg  after  it  has 
been  extended : it  is  the  analogue  of  the  tibialis  anticus. 

H A mark  the  metatarsal  phalangeal  joint;  it  is  a simple  tenon  and 
mortise  joint  firmly  bolted  together,  and  under  the  control  of  a metallic 
spring  which  brings  the  toes  straight  with  the  foot  after  they  have 
been  extended  by  the  weight  of  the  body. 

Another  automatic  appliance  of  American  invention  is  the  Palmer 
leg.  It  is  perhaps  the  best  of  the  old  style  of  artificial  limb,  and  has 
hitherto  enjoyed  the  approbation  of  the  profession  generally  for  its 
lightness,  the  ingenuity  displayed  in  its  construction  and  finish,  aud 
for  that  essential  desideratum,  efficiency.  Mr.  Palmer  describes  his 
invention  in  a pamphlet  published  by  him  in  the  following  manner : — 

“ The  articulation  of  knee,  ankle,  and  toes  consists  of  detached  ball 
and  socket  joints.  The  knee  and  ankle  are  articulated  by  means  of 
the  steel  bolts,  combining  with  plates  of  steel  firmly  riveted  to  the 
sides  of  the  leg.  To  these  side  plates  are  immovably  fastened  the 
steel  bolts.  The  bolts  take  bearings  in  solid  wood  (properly  bushed) 

! across  the  entire  diameter  of  the  knee  and  ankle,  being  stronger,  more 
reliable  and  durable  than  those  of  the  usual  construction.  All  the 
joints  are  so  constructed  that  no  two  pieces  of  metal  move  against 
each  other  in  the  entire  limb.  The  contact  of  all  broad  surfaces  is 
avoided  where  motion  is  required,  and  thus  friction  is  reduced  to  the 
lowest  degree  possible.  These  joints  often  perform  for  many  months 
without  need  of  oil  or  any  attention — a desideratum  fully  appreciated 
by  the  wearer. 

“ The  tendo-Achillis,  or  heel  tendon,  perfectly  imitates  the  natural 
one.  It  is  attached  to  the  bridge  in  the  thigh,  and  passing  down  on 
the  back-side  of  the  knee-bolt,  is  firmly  fastened  to  the  heel.  It  acts 
through  the  knee-bolt  on  a centre,  when  the  weight  is  on  the  leg,  im- 
parting security  and  firmness  to  the  knee  and  ankle-joints,  thus  obvi- 
ating all  necessity  for  knee  catches.  When  the  knee  bends  in  taking 
a step,  this  tendon  vibrates  from  the  knee-bolt  to  the  backside  of  the 
thigh.  Another  cord  descends  through  the  leg  so  as  to  allow  the  foot 
to  rise  above  all  obstructions,  in  flexion,  and  carries  the  foot  down 
again,  in  extension  of  the  leg  for  the  next  step,  so  as  to  take  a firm 
support  on  the  ball  of  the  foot.  Nature-like  elasticity  is  thus  attained, 
and  all  thumping  sounds  are  avoided. 

“ Another  tendon  of  great  strength  and  slight  elasticity  arrests  the 
motion  of  the  knee  gently  in  walking,  thus  preventing  all  disagree- 
able sound  and  jarring  sensation,  and  giving  requisite  elasticity  to  the 
knee. 

“A  spring,  lever,  and  tendon,  combining  with  the  knee-bolt,  give 


250  APPARATUS  FOR  REMEDYING  LOSS  OF  FUNCTION 


instant  extension  to  the  leg  when  it  has  been  semi-flexed  to  take  a 
step,  and  admit  of  perfect  flexion  in  sitting. 

“ A spring  and  tendons  in  the  foot  impart  proper  and  reliable  action 
to  the  ankle-joint  and  toes.  The  sole  of  the  foot  is  made  soft,  to  in- 
sure lightness  and  elasticity  of  step. 

“ The  stump  receives  no  weight  on  the  end,  and  is  well  covered  and 
protected  to  avoid  friction  and  excoriation.” 

The  Anglesea  leg  is  generally  adopted  in  England ; it  is  so  named 
after  the  Marquis  of  Anglesea,  who  exhibited  a lively  interest  in  the  per- 
fection of  the  limb,  and  used  one  himself.  Like  the  Palmer  leg,  it  con- 
sists of  a wooden  frame,  imitating  in  shape  the  natural  leg,  and  having 
the  ordinary  mortise  and  tenon  joints,  with  iron  bolts  through  their 
centres  at  the  knee  and  ankle  and  moved  by  a catgut  cord,  re- 
presenting the  flexor  muscles  of  the  leg  and  extensors  of  the  foot, 
extending  from  the  heel  to  the  knee  ; a strip  of  India-rubber  is  arranged 
in  the  forepart  of  the  instep  between  the  sole  of  the  foot  and  the  middle 
of  the  calf  of  the  leg,  for  the  purpose  of  flexing  the  foot.  The  action 
of  the  cord  is  to  extend  the  foot  when  the  leg  is  straightened,  while  in 
the  bent  position,  just  previous  to  making  a step,  it  being  relaxed,  the 
elasticity  of  the  instep  band  raises  the  toes  from  the  ground,  but  not 
in  such  a manner  or  to  such  an  extent  as  to  give  the  heel  a chance  to 
touch  the  ground  first  when  the  foot  takes  its  position  in  advance  of 
the  person,  as  is  observed  in  the  natural  gait.  The  toes  touch  first, 
and  the  weight  of  the  body  brings  the  heel  down  with  a shock. 

This  construction  also  requires  the  leg  to  be  made  shorter  than  the 
natural  one,  in  order  to  prevent  the  persons  tripping  at  every  step 
over  the  slightest  inequality  of  the  surface  upon  which  he  may  be 
walking. 

Not  possessing  the  lateral  movements  of  the  ankle,  as  in  the  Bly 
and  Ivolbe  legs,  it  is  open  to  the  objection  of  pressing  painfully  upon 
the  thigh,  and  impairing  the  stability  of  stepping  whenever  one  side 
only  of  the  foot  rests  upon  an  oblique  or  irregular  surface. 

In  France  and  Germany  elegant  artificial  limbs  are  manufactured 
after  the  models  of  Ferd.  Martin,  Mille,  Charrffire,  Bechard,  and 
Mathieu. 


CHAPTER  II. 

APPARATUS  FOR  REMEDYING  LOSS  OF  FUNCTION  OF  PARTS 

OF  THE  BODY. 

The  loss  of  function  of  parts  now  to  be  considered  affects  principally 
the  muscles  and  their  tendons  and  the  ligamentous  structures  connect- 
ing the  different  elements,  or  opposing  articular  surfaces  entering  into 
the  composition  of  the  joints.  In  their  normal  condition  the  muscles 
and  tendons  exert  themselves  uniformly  and  harmoniously  in  main- 
taining due  balance  in  the  execution  of  the  respective  offices  of  the 


OF  PARTS  OF  THE  BODY. 


251 


various  portions  of  the  human  frame  with  which  they  are  in  connec- 
tion, and  retain  in  their  position  those  organs  inclosed  by  them. 

That  the  tendons  participate  in  the  production  of  certain  deformities 
and  other  pathological  states,  as  well  as  the  muscles  with  which  they 
are  continuous,  would  seem  to  be  proven  by  the  observations  of  M. 
Jules  Gudrin,  who  dissents  from  the  doctrine  taught  by  Bichat  and 
succeeding  anatomists,  that  tendons  are  the  passive  instruments  for 
the  transmission  of  motion  originated  by  the  muscles,  and  have  no 
contractility.  Their  contractility,  it  is  true,  cannot  be  excited  like 
that  of  muscles  by  galvanism,  resembling  in  this  particular  the  dartos 
and  some  other  contractile  structures,  yet  that  it  does  occur  in  certain 
pathological  states,  such  as  the  deviation  and  deformities  in  the  joints 
following  some  of  the  gouty,  rheumatic,  and  scrofulous  inflammations 
seated  about  the  tendons,  would  seem  to  be  established  by  accurate 
observation  of  those  classes  of  disease. 

M.  Guerin  asserts  also  that  he  has  demonstrated  that,  under  a deter- 
minate condition,  such  as  constant  and  excessive  tension,  a muscle 
may  be  converted  into  a fibrous  condition,  resembling  in  every  histo- 
logical particular  its  tendon,  of  which  it  now  forms  but  a mere  pro- 
longation. Further,  he  had  observed  that  muscles  evidently  in  a 
fibrous  state  prior  to  section,  the  result  of  which  was  the  restoration 
of  their  normal  length  and  tension,  frequently,  in  the  course  of  years, 
or  even  of  months,  regain  their  fleshy  condition.  This  latter  observa- 
tion has  an  important  bearing  upon  the  mechanical  treatment  of  the 
loss  of  function  of  these  organs,  inasmuch  as  it  shows  that  though 
their  fibres  may  be  deeply  involved  in  organic  change,  atrophy,  and 
conversion  to  a fibrous  state,  the  persevering  use  of  appropriate  mea- 
sures may,  after  the  lapse  of  months,  restore  them  to  something  of  their 
pristine  vigor  and  healthfulness. 

Deformities  often  result  when  one  set  of  muscles  lose  the  habitual 
and  normal  antagonism  constantly  exerted  by  an  opposite  set  in  con- 
sequence of  their  being  paralyzed,  or  subject  to  some  organic  altera- 
tion ; or  a muscle  may  overcome,  by  exaggerated  action,  its  antagonist 
acting  normally. 

As  a general  rule,  the  abnormities  of  function  of  parts  of  the  body 
are  more  remediable  by  mechanical  appliances  when  the  unequal 
action  of  the  muscles  result  from  local  causes  than  when  it  occurs  in 
consequence  of  some  permanent  or  long-continued  morbid  alteration 
of  the  system  at  large,  as  of  the  nervous  centres.  Hence,  the  para- 
lysis of  the  limbs  from  centric  causes  is  in  general  but  little  alle- 
viated by  the  use  of  any' apparatus ; while  in  other  instances,  in  which 
local  changes  are  the  sources  of  altered  function,  much  benefit  is 
almost  always  derived  from  proper  treatment,  and  cures  are  not  un- 
frequently  obtained. 

Besides  these  causes — changes  in  the  muscles  themselves,  and  cen- 
tric or  excentric  paralysis — of  loss  and  impairment  of  function  of  the 
muscles,  a peculiar  sort  of  paralysis  is  sometimes  observed  in  hysteri- 
cal persons,  which  is  simply  the  result  of  exalted  nervous  action,  and 
implies  no  local  change  in  the  muscles  further  than  may  result  from 
the  long-continued  inaction  during  this  state,  nor  permanent  change  in 


252  APPARATUS  FOE  REMEDYING  LOSS  OF  FUNCTION 

the  nerve-centres.  Such  cases  are  frequently  cured  as  soon  as  the 
condition  upon  which  they  depend  is  removed,  whilst  any  lingering 
impairment  of  the  tone  of  the  muscles,  after  successful  general  treat- 
ment for  the  hysteria,  may  he  advantageously  met  with  exercise,  local- 
ized movements  of  the  affected  muscles,  and  appropriate  apparatus. 

As  most  of  the  diseases  falling  under  the  present  head  are  chronic, 
they  require  chronic  treatment ; an  overweening  confidence  in  appa- 
ratus of  any  description  for  a speedy  cure  will  surely  be  disap- 
pointed. The  patient  must  exert  himself  to  obtain  full  control  over 
the  affected  muscles  by  a vigorous  exercise  of  his  will,  to  develop  any 
remaining  muscular  power  while  the  surgeon  endeavors  to  supple- 
ment it  with  properly  arranged  mechanical  forces  to  overcome  the 
stronger  action  of  opposing  muscles,  and  at  the  same  time  employs 
frictions  of  the  parts  with  stimulating  applications  for  the  purpose  of 
exciting  the  capillary  circulation  and  rousing  the  dormant  nutritive 
activity.  The  mechanical  manipulations  should  be  employed  for  a 
short  time  only  at  first,  and  the  periods  gradually  lengthened  as  the 
restoration  of  function  progresses,  observing  regularity,  the  patient 
bearing  in  mind  always  that  no  good  results  can  be  accomplished  by 
fitful  and  irregular  treatment;  one,  perhaps,  carefully  observed  for  a 
few  days  and  then  dropped  for  a week,  or  some  indefinite  period,  to 
be  again  resumed  at  the  suggestion  of  his  caprice. 

SECTION  I. 

APPARATUS  FOR  REMEDYING  LOSS  OF  FUNCTION  OF  THE  MUSCLES  OF  THE 

HEAD  AND  NECK. 

Loss  of  Function  of  the  Cervical  Muscles. — It  occasionally 
happens  that  the  extensor  muscles  of  the  head,  in  consequence  of  para- 
lysis, are  unable  to  maintain  it  in  an  erect  position,  and  in  conse- 
quence the  head  falls  forward  towards  the  chest,  the  chin  reposing 
upon  the  upper  part  of  the  sternum.  The  same  result  may  also  occur 
from  the  active  and  permanent  contraction  of  the  flexors  of  the  head, 
the  erectors  opposing  little  if  any  resistance  to  their  action  in  causing 
the  displacement. 

The  course  of  treatment  to  be  pursued  should  have  especial  refer- 
ence to  the  improvement  of  the  general  health  by  tonics  and  appro- 
priate exercise,  aiding  the  restoration  of  the  power  of  the  muscles 
affected  by  systematic  localized  movements.  It  is  important  to  dis- 
criminate this  affection  from  that  in  which  the  forward  inclination  of 
the  head  depends  upon  disease  of  the  substance  of  the  vertebras 
themselves. 

To  maintain  the  head  erect,  if  no  resistance  is  offered  by  the  flexor 
muscles,  two  curved  padded  stems,  projecting  upon  either  side  of  the 
neck  from  the  upper  extremity  of  a long  metallic  lever  running  along 
the  sp;ri,  may  be  placed  beneath  the  chin;  the  head  being  rendered 
more  steady  by  a circular  strap  passing  around  the  forehead.  The 
stems  move  laterally  in  opposite  directions,  and  by  means  of  a ratchet 
screw,  controlled  by  a key  at  their  junction  with  the  vertebral  lever, 
may  be  elevated  or  depressed  at  pleasure ; the  lever  itself  takes  its 


OF  MUSCLES  OF  THE  TRUNK. 


253 


support  -upon  the  pelvis  by  two  straps  passing  around  the  body ; 
and  opposite  the  axilla  two  curved  supports  project  from  it  beneath 
the  shoulders. 

A still  more  convenient  apparatus  is  formed  by  attaching  to  the 
upper  end  of  the  vertebral  lever  two  arms  padded  at  their  extremi- 
ties to  grasp  the  sides  of  the  head,  and  capable  of  being  separated 
laterally  and  moved  upwards  and  downwards  by  ratchet-centres. 

Should  the  muscles  involved  in  the  paralysis  permit  the  head  to 
fall  sideways  upon  the  shoulder,  either  of  the  above  instruments,  with 
the  addition  of  a lateral  centre  of  motion  to  the  vertebral  lever  in  the 
neighborhood  of  the  seventh  cervical  vertebra,  will  suffice  to  sustain 
the  head  erect,  while  the  constitutional  treatment  appropriate  to  the  dis- 
eased condition  upon  which  the  paralysis  depends,  is  being  carried  out. 

SECTION  II. 

APPARATUS  FOR  REMEDYING  LOSS  OF  FUNCTION  OF  MUSCLES  OF  THE 

TRUNK. 

Apparatus  for  Remedying  Loss  of  Function  of  the  Erector 
Muscles  of  the  Spine. — In  the  natural  condition  of  the  muscles  and 
ligaments  connected  with  the  spine,  that  column  is  maintained  with 
the  greatest  facility  in  the  erect  position  without  fatigue  or  exertion. 
For  this  purpose  the  large  and  powerful  muscles  lying  in  the  verte- 
bral grooves,  with  numerous  connections  with  the  bodies  and  pro- 
cesses of  the  vertebrae,  are  admirably  adapted.  The  varied  move- 
ments of  the  body  involve  more  or  less  disturbance  in  the  equilibrium 
of  the  spine,  which  is  promptly  restored  by  the  energy  of  the  muscles 
as  soon  as  the  disturbing  influences  are  removed. 

Certain  departures  from  this  normal  action  of  the  vertebral  muscles 
and  ligaments  are  sometimes  observed,  and  are  designated  usually 
“spinal  debility.”  In  its  mildest  form  it  consists  in  a simple  debility 
of  these  tissues,  the  muscular  fibres  losing  tone,  and  partaking  in  the 
constitutional  weakness,  always  present  in  such  cases,  of  the  other 
voluntary  muscles.  The  spine  is  disposed  to  deflect  laterally  from 
the  median  line  without  any  changes  in  the  organic  integrity  of  the 
bones  themselves,  though  this  condition,  if  permitted  to  exist  for  a 
sufficiently  long  period,  will  induce  such  changes  and  also  permanent 
curvature. 

The  disease  is  observed  in  young  persons  between  the  ages  of  five 
and  fifteen,  of  a weakly  habit  of  body,  and  growing  rapidly.  In  these 
cases  the  general  health  will  be  found  to  be  more  or  less  impaired, 
the  digestive  and  assimilating  functions  deranged,  and  the  secretions 
morbid.  These  individuals  furnish  many  of  the  instances  of  permanent 
curvature  that  present  themselves  at  a later  period  of  life.  Parents 
frequently  neglect  the  physical  education  of  their  children  in  their 
anxiety  to  develop  their  mental  powers ; and  the  result  un  . r the 
system  pursued  at  the  present  time  in  our  schools  is  that  any  spinal 
debility  that  may  exist  is.  aggravated  by  the  confinement  in  the 
school-room  into  positive  deformity,  and  such  a condition  of  things 
is  established  that  months  of  patient  mechanical  treatment  will  be 


254  APPARATUS  FOR  REMEDYING  LOSS  OF  FUNCTION 

required  to  remove  curvatures  in  cases  where  continuous  and  earlv 
recourse  to  fresh  air,  exercise,  and  a proper  diet  would  have  sufficed 
to  restore  health  and  vigor  to  the  system. 

From  what  has  been  said  above,  it  may  be  gathered  that  in  case  of 
spinal  debility  it  is  of  prime  importance  to  attend  to  the  general 
health,  to  restore  the  tone  of  the  muscles  by  open-air  exercise  and 
gymnastics,  to  improve  the  digestive  and  assimilating  functions  by 
tonics — iron,  quinia,  cod-liver  oil,  cold  bathing,  &c.  Direct  the  children 
to  abstain  from  bending  the  spine  laterally  over  desks  in  studying  and 
writing,  or  indeed  assuming  any  fixed  posture  continuously. 

While  the  constitutional  treatment  is  being  conducted  upon  the 
above  principles,  some  mechanical  support  of  the  spine  may  be  had 
recourse  to.  A simple  apparatus  for  this  purpose 
is  the  one  depicted  in  Fig.  163,  consisting  of  two 
vertical  metallic  levers,  one  upon  either  side  of 
the  spine,  connected  above  with  a pad  fitting  the 
back  between  the  scapulas,  and  taking  their  point 
of  support  upon  a padded  pelvic  strap  firmly 
secured  around  the  hips.  From  the  upper  ex- 
tremities of  the  levers  two  axillary  supports  pro- 
ject beneath  the  shoulders,  each  bearing  a strap 
at  their  points,  and  intended  to  pass  over  the 
clavicle  and  scapula,  to  be  buckled  to  the  vertical 
stems.  To  confer  additional  steadiness  upon  the 
apparatus,  a laced  abdominal  band  is  connected 
with  the  levers,- and  another  one  extends  between 
the  pelvic  straps  across  the  hypogastrium. 

Dr.  Abbe,  of  Boston,  devised  an  apparatus  to 
It  is  a wire-gauze  frame  accurately  moulded  to 
the  posterior  portion  of  the  back,  and  bound  by  stout  wire.  The 
frame  is  open  at  the  loins,  where  a short  vertebral  jointed  stem  con- 
nects the  dorsal  and  pelvic  pieces  together;  the  stem  is  supported 
erect  by  two  lateral  bands  of  India-rubber,  acting  in  opposite  direc- 
tions. The  apparatus  takes  its  point  d'appui  upon  the  pelvis,  and  is 
secured  to  the  body  by  two  broad  bands,  one  encircling  the  chest  and 
the  other  the  abdomen,  lacing  in  front,  and  by  two  shoulder-straps. 
The  frame  is  light,  exercises  uniform  pressure,  and  permits  the  insen- 
sible perspiration  to  escape  freely. 

Loss  of  Functions  of  the  Muscles  of  the  Abdomen.  Hernial 
Bandages. — The  abdominal  cavity,  unlike  those  of  the  cranium  and 
chest,  is  bounded  by  yielding  walls  composed  of  muscular  and  ten- 
dinous structures,  and  is  pierced  at  points  with  certain  apertures  to 
give  egress  and  ingress  to  vessels,  nerves,  and  ducts.  It  is  constantly 
undergoing  changes  of  dimension  by  their  contraction,  by  which  the 
viscera  are  subject  to  a varying  degree  of  compression  at  all  times: 
during  active  exertion,  particularly,  the  force  is  much  increased;  and 
should  morbid  changes  or  congenital  defects  have  produced  alteration 
in  these  apertures,  the  viscera,  compressed'  from  every  direction,  are 
at  this  time  liable  to  escape  from  the  abdomen  through  the  orifices, 
and  appear  externally  under  the  form  of  a tumor.  The  sudden  manner 


OP  MUSCLES  OF  THE  TRUNK. 


255 


in  which  this  usually  takes  place  gives  the  impression  and  semblance 
of  a veritable  breaking  through  or  rupturing  of  the  walls,  and  hence 
the  injury  was  long  ago  and  is  now  popularly  known  as  rupture;  the 
more  scientific  designation,  hernia,  being  derived  from  the  Greek 
word  fp*o f,  a young  sprout. 

Hernia  is  distinguished  into  certain  species,  according  to  the  locality 
in  which  the  tumor  is  located:  if  at  the  external  orifice  of  the  inguinal 
canal,  it  is  called  inguinal;  crural,  if  at  the  orifice  of  the  crural  canal; 
and  umbilical,  when  the  rupture  occurs  at  the  navel.  These  are  the 
chief  varieties  of  hernia,  although  there  are  certain  rarer  forms,  the 
occurrence  of  which  should  be  known,  caused  by  the  viscera  appearing 
at  other  points  than  those  above  mentioned.  They  are  ventral,  the 
tumor  being  formed  over  any  accidental  or  natural  deficiency  in  the 
tendon  of  the  external  oblique  muscle ; obturator,  the  bowel  escaping 
through  the  aperture  in  the  upper  margin  of  the  obturator  or  thyroid 
membrane ; iscliiatic,  in  which  the  bowel  protrudes  at  the  ischiatic 
notch  beneath  the  gluteal  muscles;  perineal,  the  tumor  being  formed 
in  the  perineum  by  the  intestine  making  its  way  between  the  bladder 
and  rectum;  vaginal,  produced  by  the  yielding  of  the  wall  of  the 
vagina ; and  pudendal,  the  bowel  following  the  course  of  the  round 
ligament  until  it  gains  the  labium  major,  between  its  cuticular  and 
mucous  layers. 

The  mechanical  contrivance  by  which  this  abnormal  displacement 
of  the  abdominal  viscera  is  sought  to  be  corrected,  and,  under  certain 
circumstances,  cured,  is  called  a hernial  bandage,  or  truss.  The  general 
form  of  a truss  is  an  elastic  steel  spring  covered  with  buckskin,  bearing 
at  its  anterior  extremity  a small  pad  to  make  pressure  upon  the  her- 
nial opening,  and  at  the  other  a larger  pad  to  secure  a counter-pressure 
upon  the  loins;  perineal  straps  are  connected  with  the  pad  and  spring, 
to  prevent  the  instrument  being  displaced  during  the  movements  of 
the  person  wearing  it.  The  oldest  form  of  a hernial  bandage  was 
simply  a padded  pelvic  strap  with  a large  pad,  the  introduction  of  the 
steel  spring,  in  1781,  being  due  to  Mathias  Major,  since  which  time 
both  the  metallic  spring  and  the  pad  have  undergone  innumerable 
modifications,  according  to  the  peculiar  mechanical  views  of  surgeons 
or  of  manufacturers  of  the  bandages.  The  pad  has  sometimes  been 
recommended  to  be  made  small  and  oval,  at  others  large  and  round; 
now  pyriform,  and  again  triangular.  The  materials  of  which  it  is 
composed  have  been  equally  varied : in  some  trusses  it  is  composed 
wholly  of  metal,  ivory,  or  glass ; in  others,  of  soft  leather  stuffed  with 
horse-hair,  floss-silk,  fine  white  sand,  or  other  like  materials. 

An  important  feature  in  the  construction  of  a truss  is  the  manner 
of  attachment  of  the  pad  with  the  spring,  In  the  older  instruments 
- above  mentioned  this  was  effected  by  a solid  joint  which  permitted  no 
motion  of  these  parts  upon  each  other,  and  therefore  the  person  in 
moving  about  and  constantly  altering  his  attitude  caused  the  pad  to 
slip  from  over  the  hernial  opening.  The  way  of  avoiding  this  incon- 
venience is  to  connect  the  pad  and  spring  together  by  a movable  joint, 
several  varieties  of  which  have  been  adopted,  as  will  be  seen  in  the 
description  of  the  instruments  figured  below. 


256  APPARATUS  FOR  REMEDYING  LOSS  OF  FUNCTION 


The  form  of  the  truss  must  also  vary  in  shape  according  to  the 
variety  of  hernia  in  which  it  is  intended  to  be  employed. 

1.  In  inguinal  hernia,  a truss  (Fig.  164)  commonly  employed  in 
this  country,  but  nevertheless  of  little  merit,  consists  of  a metallic 

spring  immovably  attached  to  its  pad  and 
intended  to  span  almost  the  whole  circum- 
ference of  the  pelvis,  the  interval  being  made  i 
up  by  a strap  perforated  with  holes  to  receive  I 
a short  tenon  placed  upon  the  plate  of  the  pad ; ; ] 
the  pad  is  oval,  convex,  and  of  unequal  thick-  I 
ness,  the  broader  margins  being  at  its  farther 
extremity,  which  rests  upon  the  internal 
pillar  of  the  abdominal  ring,  and  at  its  lower  border,  which  should  i 
press  upon  the  spine  of  the  pubis  to  prevent  the  bowel  slipping  be- 
tween it  and  the  pad.  This  kind  of  spring  and  pad  is  selected  that  it 
may  control  the  protruding  viscera  by  pressing  upwards,  backwards,  J 
and  a little  outwards  in  the  direction  of  the  inguinal  canal,  which  is  1 
exactly  the  reverse  direction  taken  by  the  intestine  in  descending  to 
form  a tumor  exteriorly. 

This  instrument  is  applied  upon  the  side  opposite  that  upon  which 
the  hernia  is  seated. 

As  there  may  be  two  or  even  three  ruptures  in  the  same  subject,  an 
additional  pad  has  occasionally  been  attached  to  this  instrument ; but 
the  arrangement  is  a very  bad  one,  as  it  produces  unequal  pressure 
and  is  otherwise  very  insecure. 

The  improvement  upon  this  is  to  place  the  two  small  pads  at  the 
extremities  of  the  metallic  spring,  in  double  inguinal  hernia,  for  ex- 
ample, and  a large  pad  in  its  centre  to  make  the  counter-pressure  over 
the  lumbar  region. 

Fig.  165.  Fig.  166. 


The  objections  to  the  immovable  pad  already  stated  were  so  evident 
as  to  lead  to  numerous  attempts  to  obviate  them ; and  the  efforts  were 


Fig.  164. 


Single  inguinal  truss. 


OF  MUSCLES  OF  THE  TRUNK. 


257 


crowned  with  more  or  less  success.  Salmon  and  Ody  introduced  a 
truss  (Fig.  165)  which  has  been  in  high  favor  for  years,  and  is  now 
extensively  employed.  It  consists  of  a spring  spanning  half  the 
body  from  the  spine  to  the  abdominal  ring  upon  the  sound  side. 
The  pad  is  oval,  and  attached  to  the  spring  by  a ball  and  socket  joint, 
so  that  it  participates  in' all  the  motions  of  the  body,  and  therefore  is 
not  easily  displaced.  In  double  inguinal  hernia,  two  pads  are  fastened 
in  the  same  manner  to  the  spring  which  takes  its  point  of  support  by 
a broad  pad  upon  the  spine.  (Fig.  166.) 

Coles’  truss  differs  from  that  of  Salmon  and  Ody’s,  in  that  the  spring 
extends  from  the  spine  to  the  inguinal  ring  on  that  side  upon  which 
the  hernia  is  seated  ; and  instead  of  the  ball  and  socket  joint,  the  pad, 
which  is  long  and  pyriform,  is  enabled  to  participate  in  the  movements 
of  the  body  by  means  of  a flat  spiral  spring  attached  to  its  anterior 
surface. 

Dr.  Todd  suggested  a modification  of  the  spring  (Fig.  167)  in  order 
to  obtain  a more  energetic  pressure  upwards  and  backwards,  so  that 
instead  of  passing  around  the  pelvis  as  in  the  two  former  instruments 
it  mounted  over  the  crest  of  the  ilium  and  terminated  in  a small  oval 
: pad. 

Wickham  has  introduced  a ratchet-wheel  into  the  composition  of 
the  pad,  so  that  by  means  of  a screw  the  pressure  may  be  increased 
or  diminished  at  pleasure. 

To  obtain  the  same  result  Dr.  Arnott  had  previously  proposed  that 
a chain  be  attached  to  the  spring  along  its  length  capable  of  being 
. controlled  by  a key. 

Fig.  167.  Fig.  168. 


In  certain  obstinate  cases  of  inguinal  rupture,  Mr.  Bigg,  of  London, 
has  succeeded  in  retaining  the  bowel  reduced,  by  means  of  a triple- 
lever  truss  (Fig.  168)  which  exercises  force  in  three  different  lines. 
He  explains  this  kind  of  an  apparatus  in  the  following  manner:  “ A, 
B,  C are  three  springs  of  different  lengths,  moving  freely  by  means 
17 


258  APPARATUS  FOR  REMEDYING  LOSS  OF  FUNCTION 

of  small  staples  on  the  margin  of  a triangular  pad.  D is  a soft  padded 
leather  or  silk  band  passing  around  the  pelvis  and  containing  within 
it  the  three  springs.  E is  a silk  strap  fixed  to  the  lower  spring.  A, 
a small  button  placed  in  the  centre  of  the  pad  acts  upon  the  springs, 
and  on  being  turned  increases  or  diminishes  the  pressure  upon  the 
hernial  ring.  Owing  to  the  various  lengths  and  positions  of  the 
springs  each  acts  in  a different  direction  upon  the  rupture.  A tilts 
the  lower  edge  of  the  pad  upwards;  B acts  equally  upon  the  whole 
surface  of  the  pad,  pressing  it  inwards  and  upwards ; while  C acts  upon 
the  centre  of  the  pad,  forcing  it  directly  inwards.  By  the  combined 
action  of  the  three  springs  the  tendency  of  a severe  rupture  to  slip 
beneath  the  pad  is  effectually  controlled. 

In  the  truss  of  Stagner  and  Hood,  improved  by  Chase  and  others, 
the  pad  is  made  of  birch  or  cedar,  a material  possessing  lightness  and 
at  the  same  time  sufficient  closeness  of  texture  as  not  to  absorb  the 
secretions  of  the  part  to  which  it  is  applied,  or  to  wear  out ; it  is  oval 
in  shape  and  convex  upon  its  ventral  surface;  and  articulated  with 
the  spring  by  a joint  which  permits  the  angle  formed  by  it  with  the 
spring  to  be  varied  at  pleasure  so  as  to  secure  the  most  perfect  adapta* 
tion  to  the  surface.  The  spring  is  constructed  in  the  usual  manner  and 
spans  two-thirds  of  the  body,  its  extremities  being  joined  by  a letter 
strap  perforated  with  holes  to  be  fastened  to  a button  just  beyoncrtha 
pad ; the  counter-pressure  is  made  by  a round  pad  upon  the  back  part 
of  the  spring.  When  the  apparatus  is  applied  in  order  to  prevent  its 
slipping  up  over  the  hips,  a thigh-strap  is  attached. 

The  best  truss  I am  acquainted  with,  for  the  treatment  of  inguinal 
hernia,  is  the  one  seen  in  Fig.  169,  manufactured  by  the  surgical 

instrument  makers  of  this  city  and  sold 
under  the  name  of  “ Hood’s  truss.”  It 
is  constructed  of  two  simple  trusses 
connected  together  by  a curved  spring 
spanning  the  space  between  the  two 
anterior  pads ; the  posterior  pads  rest 
upon  the  fleshy  masses  upon  either 
side  of  the  spine,  and  are  connected 
by  a leather  strap.  When  properly 
applied  it  is  almost  impossible,  by  any 
movements  of  the  body,  to  displace  this  instrument  from  the  position 
assigned  it  upon  the  pelvis  and  groin.  If  the  hernia  is  single,  but  one 
of  the  anterior  oval  plates  is  then  padded,  the  other  is  simply  covered 
with  buckskin  to  prevent  the  skin  being  chafed ; in  double  hernia,  of 
course,  both  pads  are  used. 

Besides  the  metallic  spring  truss,  there  are  those  in  which  the  elastic 
force  of  India-rubber  is  employed.  M.  Dupre’s  hernia  bandage  is  of 
this  description ; as  it  has  been  found  of  service  in  many  cases,  and  is 
now  frequently  employed  in  France,  a brief  description  of  it  may  be 
acceptable.  The  frame  of  the  instrument  (Fig.  1705  is  formed  of  a 
stout  wire,  bent  to  adapt  itself  to  the  outlines  of  the  pubis  and  inguinal  1 
regions,  and  supporting  in  front  one  or  two  pads,  according  as  the 
hernia  is  single  or  double.  To  the  extremities  of  the  arc  an  elastic 


Fig.  169. 


OF  MUSCLES  OF  THE  TRUNK. 


259 


band,  furnished  with  buckles  to  fasten  behind,  is  attached,  and  by  it 
the  pressure  of  the  pads  is  regulated  at  will. 

Fig.  170. 


A bandage  composed  entirely  of  elastic  material  has  been  occa- 
■sionally  recommended  in  the  treatment  of  inguinal  rupture.  Strips 
of  India-rubber  are  fastened  together  in  a spiral  manner,  and  their 
contraction  maintains  an  elastic  pad  over  the  inguinal  ring.  In  this 
manner,  M.  Bourgeand  has  devised  an  apparatus  for  preventing  hernial 
[extrusions,  consisting  of  inflated  India-rubber  pads,  which  are  confined 
!otf'ej;  the  abdominal  rings  and  inguinal  canals  by  a broad  elastic  band. 
It  i?  intended  to  obviate  the  supposed  atrophic  effects  of  the  pressure 
!of  the  pad  of  the  ordinary  truss  upon  the  cellular  and  muscular  tissues 
of  the  groin,  which  thereby  weakens  the  part,  by  substituting  the 
gentle,  uniform  and  effective  pressure  of  an  air  pad.  Another  advan- 
tage claimed  for  the  apparatus  is  that  the  abdomen  is  gently  com- 
pressed by  the  elastic  belt,  and  the  intestines  thereby  effectually  sup- 
ported in  their  normal  site,  so  that  there  can  be  but  little  disposition 
on  their  part  to  protrusion. 

Experience  has  not  confirmed  the  superiority  of  Bourgeand’s  con- 
trivance over  the  spring  truss,  and  it  is  therefore  now  little  used.  I 
have  employed  a modification  of  it  with  advantage  in  the  treatment 
of  large  irreducible  hernias ; giving  the  air-pad  a sufficient  concavity 
;o  embrace  the  tumor. 

In  the  moc-main  truss  the  elastic  resistance  of  a spring  is  employed 
n the  following  manner  : a padded  belt  surrounds  the  pelvis  bearing 
i large  oval  pad  stuffed  with  floss  silk,  and  having  attached  to  it  a 
short  metallic  spring.  The  pad  is  kept  pressed  against  the  inguinal 
canal  by  a thigh  strap  fixed  to  the  end  of  the  spring. 

When  the  viscera  have  escaped  from  the  abdomen  and  found  their 
vay  into  the  scrotum,  forming  a moderate-sized  tumor,  considerable 
nore  difficulty  will  be  encountered  in  keeping  the  inguinal  canal  and 
ts  rings  closed  than  in  simple  cases  of  bubonocele,  or  where  the  tumor 
Exists  in  the  groin,  and  for  which  the  trusses  above  described  are 
especially  adapted. 

The  action  of  a truss  for  oscheocele  or  scrotal  hernia  should  be  to 
dose  the  entire  length  of  the  passage  followed  by  the  escaping 
; towel.  The  best  form  of  a bandage  to  effect  this  will  be  one  with 
large  fusiform  pad  supported  by  a spring  encircling  the  pelvis, 
nd  having  its  lower  end  firmly  held  in  contact  with  the  parts  beneath 


260  APPARATUS  FOR  REMEDYING  LOSS  OF  FUNCTION 


by  a thigh-strap  passing  around  the  thigh  opposite  the  side  upon 
which  the  hernia  exists,  and  fastening  above  to  the  spring.  The  appli- 
cation of  a truss  with  a large  concave  pad  to  an  irreducible  hernia  may 
in  time  effect  its  reduction,  but  such  instruments  should  be  employed 
with  prudence.  In  some  of  these  instances  of  large  scrotal  hernias, 
irreducible  in  consequence  of  adhesions  established  with  surrounding 
parts,  the  only  mechanical  contrivance  either  advisable  or  practicable  « 
is  a simple  suspensory  bandage  which  will  ameliorate  the  patient’s 
condition,  and  enable  him  to  pursue  his  avocations  in  life  with  com- 
parative comfort. 

2.  Crural  or  femoral  hernia.  The  truss  (Fig.  171)  employed  in  the 
treatment  of  this  form  of  rupture  possesses  the 
same  general  features  as  that  for  inguinal  hernia, 
viz : a metallic  spring  and  pad ; but,  from  the 
fact  that  the  crural  ring  is  inferior  and  external 
to  the  external  abdominal  ring,  the  neck  of  a 
crural  truss  must  be  longer,  and  the  pad  must 
form  a less  oblique  angle  with  the  spring  which 
should  always  span  the  diseased  side.  As  the 
pad,  which  must  be  peculiarly  shaped,  reposes 
in  the  folds  of  the  groin,  it  is  apt  to  be  displaced  . 
by  the  movements  of  the  thigh,  and  therefore  a 
thigh  strap  becomes  indispensable. 

3.  Umbilical  hernia  is  most  frequently  met 
with  in  infancy  in  consequence  of  a tardy  closure 
of  the  umbilicus  during  development,  and  in 
adults  principally  among  the  corpulent.  When 
the  viscertt  have  been  restored  to  the  abdominal 
cavity  they  are,  in  general,  easily  retained  there 
by  a properly  constructed  truss,  a simple  form 
of  which  for  an  infant,  or  in  a mild  case  in  the 
adult,  may  be  prepared  with  gum  elastic  in  the  shape  of  a band  three 
or  four  inches  deep  and  lacing  behind.  In  front,  a pad,  a little  larger 
than  the  umbilical  opening  and  slightly  convex,  is  attached  to  the 
belt  to  restrain,  by  its  pressure,  the  extrusion  of  the  bowel.  The  size 
of  the  pad  is  an  important  point  in  the  treatment  of  this  disease ; if  it 
is  too  small,  the  elastic  band  or  metallic  spring  (if  that  is  used)  is  apt 
to  sink  it  into  the  opening,  and  thus  defeat  the  very  object  that  was 
had  in  view  in  employing  it. 

Should  the  elastic  force  of  the  India-rubber  not  succeed  in  restrain-  . 
ing  the  issue  of  the  viscera,  then  recourse  must  be  had  to  a metallic  ( 
spring  encircling  the  body  (Fig.  172)  and  attached  to  a compressive  { 
pad  in  front.  An  irreducible  umbilical  hernia  may  be  benefited,  and  i 
in  time  rendered  reducible,  by  constructing  the  anterior  pad  with  a 
concave  ventral  surface  which  is  gradually  to  be  diminished  in  pro- 
portion to  the  lessening  size  of  the  tumor  under  the  pressure,  until  a I 
convex  pad  may  be  employed. 

If  no  well-constructed  pad  is  at  hand,  as  those  above  mentioned,  a 
simple  leathern  or  elastic  belt  having  an  oval  pad,  or,  better  still,  an  ; 


Fig.  171. 


OF  MUSCLES  OF  THE  TRUNK. 


261 


air  pad,  attached  to  its  middle,  will  answer  as  a substitute  for  them, 
and  will  do  good  service. 


Fig.  172. 


4.  Ventral  hernia  may  be  treated  with  the  same  instruments  as  those 
used  in  the  umbilical  form  of  rupture,  modifying  them,  of  course,  to 
suit  the  necessities  of  individual  cases. 

5.  Obturator  or  thyroid  hernia,  occupying,  as  it  does,  a position 
ibeneath  the  ramus  of  the  pubis,  may  be  effectually  kept  reduced  by  a 
truss  similar  to  one  adapted  for  inguinal  hernia,  with  the  difference 
that  its  neck  should  be  more  elongated  and  the  pad  smaller,  more 
convex,  and  oval. 

6.  Ischiatic  hernia  is  more  difficult  of  management,  but  is  yet  capa- 
ble of  being  controlled  by  a truss  formed  of  an  elastic  spring  to 
encircle  the  pelvis,  and  an  oval  pad  to  rest  on  that  part  of  the  gluteal 
region  corresponding  with  the  ischiatic  notch. 

7.  Perineal  hernia  requires  a truss  of  rather  peculiar  construction 
sonsisting  of  a padded  pelvic  strap,  from  the  posterior  and  central 
part  of  which  a curved  metallic  spring  projects  as  far  as  the  tumor, 
md  bearing  upon  the  extremity  a firm  oval  pad  to  exercise  com- 
pression upon  the  protrusion. 

8.  Vaginal  hernia  can  be  most  effectually  treated  by  properly  con- 
structed pessaries,  an  account  of  which  will  be  found  further  on. 

9.  Rectal  hernia,  resembling  vaginal  rupture  in  occurring  in  one  of 
he  natural  canals  of  the  body  the  walls  of  which  form  the  sac  con- 
aming the  displaced  intestine,  like  it,  also  requires  pessaries,  the 
proper  form  of  which  will  be  seen  in  a subsequent  section. 

10.  Pudendal  hernia,  formed  by  the  bowel  following  the  course  of 
he  round  ligament  in  the  inguinal  canal,  is  the  analogue  of  inguinal 
■upture  in  the  male,  and  requires  for  its  treatment  the  inguinal  truss 
ilready  described. 

Application  of  Tkusses. — It  is  of  the  first  importance  to  secure 
. properly  made  hernial  bandage  for  each  individual  case  under 
reatment,  and  for  this  purpose  the  surgeon  should  take  the  necessary 
measurements  of  the  pelvis  of  the  patient.  This  may  be  done  with  a 
imple  tape  measure,  placing  its  extremity  upon  the  hernial  tumor 
nd  carrying  the  line  horizontally  around  the  pelvis  upon  the  same 
ide  to  the  spine,  and  noting  the  number  of  inches,  which  will  be  the 


262  APPARATUS  FOR  REMEDYING  LOSS  OF  FUNCTION 

length  for  the  spring.  A better  way,  however,  if  it  is  practicable,  is  to 
take  the  measure  with  a piece  of  wire,  which  will  give  at  the  same 
time  the  contour  of  the  hip.  A great  deal  of  injury  has  been  perpe- 
trated by  the  vendors  of  ready-made  trusses,  who  sell  their  instruments 
indiscriminately  without  regard  to  the  condition  of  the  patient,  or 
their  adaptation  to  the  parts  to  which  they  are  to  be  applied  : and  thus 
a person,  lulled  to  a sense  of  security  by  the  fact  of  his  having  on  a 
truss,  without  considering  its  efficiency,  may  become  suddenly  a victim 
to  strangulation  by  indulging  even  in  an  ordinary  degree  of  exertion; 
a result  that  would  not  have  taken  place  at  all,  had  he  attended  to  this 
point  and  secured  a really  good  instrument. 

The  surgeon  having  procured  a properly  fitting  truss,  proceeds  to 
apply  it  by  placing  the  patient  in  a horizontal  position,  and  when  the 
entire  contents  of  the  hernial  sac  have  been  returned  into  the  abdo- 
men, he  places  the  first  two  or  three  fingers  of  the  left  hand  upon  the 
ring  and  prevents  their  descent,  while  with  the  right  hand  the  truss 
is  unfolded  and  slipped  around  the  pelvis,  the  compressing  pad  being 
gradually  brought  over  the  ring  as  the  fingers  are  withdrawn.  The 
straps  are  then  to  be  secured  immediately,  and  the  patient  directed  to 
rise  and  move  about,  to  cough,  and  change  his  position,  while  the 
surgeon  makes  sure  that  all  is  secure  by  a careful  examination.  But 
if  the  bowel  should  descend,  the  truss  must  be  manipulated  anew  until 
a complete  retention  is  secured. 

For  the  first  few  weeks,  perhaps,  the  patient  may  feel  a little  annoy- 
ance from  the  truss;  this  will  speedily  disappear  if  the  spring  is  not 
too  strong,  a circumstance  that  may  be  known  by  the  pad  not  leaving 
a depression  in  the  part  beneath  it.  The  only  amount  of  pressure, 
either  required  or  advisable,  is  that  just  sufficient  to  prevent  the  intes- 
tine escaping  from  the  abdomen : this  important  point  is  sometimes 
overlooked,  and  the  result  is,  that  with  such  stiff  truss-springs  as  are 
often  furnished,  inflammatory  swelling  of  the  testicle  and  scrotum,  vari- 
cocele, excoriation  of  the  skin,  and  absorption  of  the  tissues  compressed, 
are  some  of  the  accidents  liable  to  follow  their  use.  The  spermatic 
cord  must  also  be  carefully  exempted  from  injurious  pressure  of  the  pad. 
The  truss  is  essentially  a palliative  instrument  in  patients  beyond  the 
18th  or  19th  year;  but  in  children  it  is  generally  successful  in  oblite- 
rating the  canal ; and,  faithfully  employed,  will  effect  a cure  in  from 
twelve  to  eighteen  months.  In  adults  this  result  is  rarely  obtained, 
even  after  years  of  perseverance  with  the  use  of  the  truss : the  only 
advantage  accruing  from  its  employment,  though  that  is  a very  im- 
portant one,  is  the  retention  of  the  abdominal  viscera  in  their  natural 
cavity,  and  freedom  from  the  chance  of  their  becoming  strangulated. 

The  instrument  must  be  worn  constantly,  day  and  night : and  it  will 
be  well,  during  any  unusual  exertion,  violent  coughing,  sneezing,  and 
the  like,  to  support  the  pad  with  the  fingers.  During  warm  weather, 
to  prevent  excoriation,  it  will  be  advisable  to  interpose  between  the 
pad  and  the  skin  a fold  of  soft  linen.  Some  persons  are  in  the  habit, 
• occasionally,  for  the  same  purpose,  of  wearing  the  truss  over  an  under- 
garment, a plan  which  cannot  be  too  strongly  condemned,  for  the  rea- 


OP  MUSCLES  OF  THE  TRUNK. 


26S 


son  that  the  pad  is  thereby  constantly  liable  to  be  displaced,  and  to 
permit  the  bowel  to  escape. 

The  Taxis. — The  reduction  of  hernia  by  manipulation  is  techni- 
cally called  taxis.  As  there  are  certain  general  rules  to  be  observed 
in  employing  the  taxis  in  the  different  kinds  of  hernia,  a cursory 
allusion  to  them  in  this  place  will  save  further  repetition  when  we 
come  to  consider  each  variety  separately. 

Position. — The  best  position  to  place  the  patient  in  to  obtain  as 
perfect  a relaxation  of  the  muscles  as  possible,  is  the  horizontal, 
with  the  hip  elevated,  and  the  thighs  somewhat  flexed.  Some  per- 
sons prefer  to  place  the  patient  upon  a sofa,  with  its  end  sloping 
upwards,  over  which  his  legs  hang,  while  his  head  rests  upon  its  centre, 
in  a lower  plane  than  the  rest  of  the  body.  Although  the  position  of 
the  patient  will  contribute  much  towards  relaxing  the  muscles,  there 
are  other  adjuvants  still  more  potent. 

Ansesthetics. — It  was  formerly  the  custom  to  produce  muscular  relax- 
ation by  the  warm  bath,  the  administration  of  tartar  emetic,  injections 
of  an  infusion  of  tobacco,  and  copious  venesection;  but  the  discovery 
and  introduction  of  the  ansesthetics  in  surgery  have  well-nigh  rendered 
the  use  of  these  agents  obsolete,  though  under  circumstances  where 
chloroform  or  ether  are  not  attainable,  these  means  may  be  had 
recourse  to,  and  will  prove  of  service.  It  has,  also,  been  recommended 
that  cold  be  applied  to  the  scrotum  to  contract  and  to  condense  the  con- 
tents of  the  sac  for  facilitating  their  return.  Powdered  ice,  wrapped 
up  in  a piece  of  oiled  silk,  or  cold  water,  applied  to  the  bottom  of  the 
tumor,  will  be  as  good  a plan  as  any  to  obtain  the  physiological  action 
of  cold. 

In  the  application  of  compression,  which  requires  the  greatest  dis- 
cretion as  to  its  amount,  duration,  and  direction,  it  must  always  be 
borne  in  mind  that,  although  the  taxis  will  often  succeed  in  accom- 
plishing the  reduction  of  the  hernia,  there  are  numerous  cases  in 
which  it  will  fail,  and  herniotomy  is  required ; then  the  future  wel- 
fare of  the  patient  as  to  his  chance  of  surviving  will  depend,  to  a 
great  extent,  upon  the  amount  and  character  of  the  manipulation  to 
which  the  intestine  has  been  subject  in  the  taxis.  The  amount  of 
compression  that  may  be  prudent,  without  jeopardizing  the  subsequent 
well-being  of  the  patient,  should  the  taxis  fail,  and  an  operation  be- 
come necessary,  may  be  exercised  by  seizing  the  hernial  tumor  in  the 
palm  of  the  hand,  and  with  the  fingers,  knead  gently  the  part,  until  its 
contents  give  the  sensation  of  uniformity,  when  gentle  traction  should 
be  made  upon  it  to  draw  down  the  intestine  a little  to  disengage  it 
from  the  ring.  Then  the  pressure  of  the  hand  must  be  exercised 
upon  the  tumor  at  every  part  embraced,  so  that  the  upper  portion  of 
its  contents  alone  may  press  upon  the  ring,  while  the  fingers  of  the 
opposite  hand  are  employed  in  pressing  the  intestine,  little  by  little, 
through  the  ring  in  an  appropriate  direction.  If  the  whole  tumor  is 
compressed  directly  against  the  ring  its  contents  will  spread  out  over 
it,  and  frustrate  the  surgeon’s  efforts. 

The  duration  of  the  compression  should  not  be  too  long,  as  the  case 
becomes  more  and  more  grave  with  the  duration  of  the  strangulation, 


264  APPARATUS  FOR  REMEDYING  LOSS  OF  FUNCTION 

and  the  chances  of  success  of  herniotomy  diminish  in  a direct  propor- 
tion. After  the  patient  has  been  fully  etherized,  and  taxis  employed 
judiciously,  for  a period  longer  or  shorter,  according  to  the  circum- 
stances of  the  case,  and  the  reduction  cannot  be  accomplished,  another 
trial  may  be  made  in  a few  minutes,  by  changing  the  patient’s  posi- 
tion, or  having  recourse  to  another  method  of  taxis  than  the  one  at 
first  tried.  Should  this  in  like  manner  fail,  the  surgeon  had  better 
suspend  his  efforts,  and  subject  the  patient  to  herniotomy  without 
delay. 

The  direction  of  compression  must  vary  in  the  different  forms  of 
hernia,  and  will,  therefore,  be  considered  further  on. 

In  applying  the  taxis  it  will  be  advisable  to  endeavor  to  ascertain 
the  character  of  the  contents  of  the  hernial  sac  by  a careful  examina- 
tion, so  that  the  parts  may  be  reduced  in  the  reverse  order  of  their 
extrusion ; that  is,  intestine  first,  and  then  omentum.  The  constitu- 
ents of  a hernial  tumor  may  be  defined  to  a certain  extent  by  its  phy- 
sical characters.  The  descent  of  the  bowel  containing  gaseous  mat- 
ter (enterocele)  will  produce  a tumor  more  or  less  elastic,  smooth,  and 
uniform  to  the  touch,  and  is  usually  larger,  more  sensitive,  and  more 
easily  reduced  than  one  containing  omentum  only,  the  reduction  tak- 
ing place  sudden^,  and  accompanied  by  a peculiar  gurgling  noise. 
The  presence  of  omentum  in  the  tumor  (epiplocele)  confers  upon  it  an 
irregular,  soft,  and  doughy  feel ; and  the  reduction  takes  place  slowly 
and  without  noise;  it  is  usually  smaller  than  an  enterocele.  When 
the  hernial  protrusion  contains  both  intestine  and  omentum  (entero- 
epiplocele)  it  will  partake,  in  a measure,  of  the  characteristics  of  both 
the  preceding  varieties,  a part  of  it  feeling  elastic,  -while  the  other  is 
doughy. 

1.  Taxis  of  Inguinal  Hernia. — As  already  stated,  inguinal  hernia  is 
formed  by  the  intestine  escaping  at  the  external  abdominal  ring,  and 
it  is  said  to  be  indirect  or  external,  when  the  bowel  enters  the  internal 
abdominal  ring  and  courses  the  inguinal  canal,  and  direct  or  internal 
when  it  escapes  by  forcing  before  it  the  conjoined  tendon  of  the  inter- 
nal oblique  and  transversalis  muscles.  In  the  former  case  the  direction 
will  be  downwards,  inwards,  and  forwards,  and  in  the  latter  forwards 
and  downwards.  The  terms  internal  and  external  inguinal  hernia 
refer  to  the  position  of  the  neck  of  the  sac,  as  regards  the  epigastric 
artery.  If  the  protruding  viscera  are  arrested  in  the  groin,  the  her- 
nia receives  the  name  of  bubonocele,  while  it  is  designated  oscheocele 
when  they  are  contained  in  the  scrotum. 

In  using  the  taxis  in  inguinal  rupture,  the  patient  should  be  placed 
in  the  position  indicated  above,  to  relax  the  abdominal  muscles  as 
thoroughly  as  practicable,  and  then  be  completely  anesthetized.  The 
surgeon  takes  his  position  upon  the  side  of  the  patieut  upon  which 
the  hernia  is,  grasps  the  tumor  in  the  palm  of  one  of  his  hands  and 
compresses  it  to  diminish  its  bulk,  while  with  the  fingers  of  the  other 
hand  placed  over  the  external  abdominal  ring,  he  endeavors  to  press 
the  contents  of  the  upper  part  of  the  tumor  into  the  abdomen,  little 
by  little,  until  the  whole  of  the  displaced  viscera  shall  have  been 
restored  to  their  natural  cavity.  The  pressure  must  be  exercised  in 


OF  MUSCLES  OF  THE  TRUNK. 


265 


: indirect  hernia  upwards,  a little  backwards  and  outwards ; while  in 
the  direct  variety  the  line  of  pressure  ought  to  be  upwards  and  back- 
wards. In  long-standing  cases  of  indirect  rupture,  the  two  rings  are 
drawn  more  or  less  into  the  same  line,  so  that  the  manipulation  in  these 
cases  will  have  to  be  modified,  so  that  the  pressure  may  bear  upwards 
and  almost  backwards,  as  in  direct  hernia.  Generally,  as  soon  as  the 
1 constricted  portion  of  the  intestine  is  replaced,  the  remainder  will 
slip  in  immediately. 

A plan  for  the  taxis,  as  recommended  by  M.  Despres,  in  small  in- 
guinal hernia,  is  thus  described  by  Jamain:  The  surgeon  applies  the 
cubital  border  of  the  left  hand  a little  above  the  pedicle  (or  neck)  of  the 
hernia,  strokes  it  in  such  a manner  as  to  draw  the  tumor  into  the  scrotum; 
then  compresses  the  tumor  with  the  right  hand  more  or  less  firmly, 
according  to  the  volume  of  the  hernia;  and  the  hernia  enters,  after 
some  efforts,  of  which  the  surgeon  regulates  the  intensity  and  duration. 

This  is  the  way  M.  Desprds  explains  the  mechanism  of  this  process: 
1.  He  fixes  the  neck  of  the  sac,  the  principal  obstacle  to  the  reduc- 
tion. 2.  In  pressing  upon  the  tumor  he  diminishes  the  volume  of  the 
intestine  at  the  orifice  of  the  sac.  3.  In  pressing  with  the  right  hand 
he  causes  the  intestinal  loop  to  execute  a movement  analogous  to  that 
of  two  fingers  opening  a purse. 

Dr.  Wise,  of  India,  describes  in  the  London  Journal  of  Medicine 
the  following  way  of  making  the  taxis,  which  he  states  to  have  been 
followed  by  success:  “ Place  the  patient  on  a table,  and  having  folded 
a long  sheet  several  times  on  itself,  carry  it  around  the  lower  part  of 
his  pelvis,  twisting  it  on  itself,  in  front  and  again  at  the  sides,  so  as 
to  enable  the  assistants,  who  stand  on  each  side  to  hold  the  extremi- 
ties of  the  sheet,  and  pull  them  gently  upwards  or  towards  the 
patient’s  head,  while  a third  assistant  holds  the  feet,  and  the  surgeon 
makes  the  taxis.  As  the  gut  immediately  above  the  strangulated 
portion  is  often  superficial,  and  distended  with  flatus  and  liquid,  it 
will  be  drawn  upwards  from  the  hernial  sac,  whilst  the  return  of  the 
protruded  portion  is  favored  by  the  taxis  practised  by  the  surgeon.” 

I have  succeeded  in  reducing  two  cases  of  strangulated  inguinal 
hernia  by  a mode  highly  recommended  by  M.  Seutin.  It  is  effected 
in  the  following  manner : “ The  patient  is  laid  upon  his  back,  with 
the  pelvis  raised  much  higher  than  the  shoulders,  in  order  that  the 
intestinal  mass  may  exert  traction  upon  the  herniated  portion.  The 
knees  are  flexed,  and  the  body  is  slightly  turned  to  the  opposite  side 
to  that  on  which  the  hernia  exists.  The  surgeon  ascertains  that  the 
hernia,  habitually  reducible,  cannojt  be  returned  by  continuous  and 
moderate  taxis.  He  next  seeks  with  his  index  finger  for  the  aperture 
that  has  given  issue  to  the  hernia,  pushing  up  the  skin  sufficiently 
from  below  in  order  not  to  be  arrested  by  its  resistance.  The  ex- 
tremity of  the  finger  is  passed  slowly  in  between  the  viscera  and  the 
herniary  orifice,  depressing  the  intestine  or  omentum  with  the  pulp 
of  the  finger.  This  stage  of  the  procedure  demands  perseverance,  for 
at  first  it  seems  impossible  to  succeed.  The  finger  is  next  to  be 
curved  as  a hook,  and  sufficient  traction  exerted  on  the  ring  to  rup- 
ture some  of  the  fibres,  giving  rise  to  a cracking  very  sensible  to  the 


266  APPARATUS  FOR  REMEDYING  LOSS  OF  FUNCTION 

finger,  and  sometimes  to  tfie  ear.  When  this  characteristic  crack  is 
not  produced,  the  fibres  must  be  submitted  to  a continuous  forced 
extension,  which,  by  distending  them  beyond  the  agency  of  their 
natural  elasticity,  generally  terminates  the  strangulation.  This  mode 
of  procedure  is  less  applicable  to  Gimbernat’s  ligament,  the  hooking 
and  tearing  of  which  are  more  difficult  than  in  the  case  of  the  inguinal 
ring.  Considerable  strength  has  sometimes  to  be  exerted,  and  the 
index  finger  becomes  much  fatigued.  When,  in  consequence  of  the 
narrowness  of  the  ring,  the  finger  does  not  at  once  penetrate,  it  is  to 
be  pressed  firmly  against  the  fibrous  edge,  and  inclined  towards  the 
hernia.  After  a time  the  fibres  yield  and  the  finger  passes.  When 
the  finger  becomes  fatigued  it  is  not  to  be  withdrawn,  but  it  should 
be  supported  by  the  fingers  of  an  intelligent  assistant,  who  seconds 
the  action  it  is  desired  to  produce.  In  inguinal  hernia,  the  traction 
should  not  be  exerted  with  the  finger  upon  Poupart’s  ligament,  but 
in  a direction  from  within  outwards,  and  from  below  upwards,  by 
which  the  aponeurotic  layers  between  the  two  ligamentous  pillars  con- 
stituting the  inguinal  aperture  are  easily  torn  through. 

“The  ring  is  then  enlarged  by  this  tearing,  just  as  if  it  had  been 
divided  by  a cutting  instrument,  or  largely  dilated,  and  reduction 
takes  place  easily  by  performing  the  taxis  in  a suitable  direction.” 

Care  should  be  taken  that  the  whole  mass  of  the  hernia  may  not 
slip  into  the  abdomen  while  the  constriction  remains  unrelieved.  If 
the  accident  should  result,  the  patient  should  be  directed  to  make 
straining  efforts  to  reproduce  the  hernia,  when  the  taxis  may  be 
again  had  recourse  to ; if  this  be  not  successful,  herniotomy  alone 
remains  to  be  performed,  and  this  is  then  often  followed  by  a fatal 
result. 

After  the  successful  employment  of  the  taxis  in  inguinal  hernia,  the 
patient  should  be  kept  in  the  horizontal  position  a few  days,  and  an 
appropriate  truss  applied. 

2.  Taxis  of  Crural  Hernia.  — The  intestine  passing  through  the 
femoral  canal  and  saphenous  opening  in  the  fascia  lata  will  form  a 
tumor  of  smaller  size  than  that  observed  in  inguinal  hernia,  with  its 
greater  diameter  transverse,  and  located  at  a point  somewhat  lower 
and  a little  external  to  the  external  abdominal  ring.  By  placing  the 
finger  upon  the  horizontal  ramus  of  the  pubic  bone  the  tumor  will  be 
found  to  be  situated  below  it. 

From  the  peculiar  conformation  of  the  crural  canal,  in  performing 
the  taxis  it  will  be  necessary  to  place  the  patient  in  the  horizontal  pos- 
ture, and  in  order  to  relax  the  parts  about  the  internal  femoral  ring 
and  saphenous  opening,  flex  the  thigh  upon  the  abdomen,  adduct  and 
rotate  it  inwards.  Then  the  surgeon,  having  thoroughly  anesthetized 
the  patient,  he  takes  his  place  upon  that  side  of  him  opposite  the  one 
upon  which  the  hernia  is  situated,  and  grasps  the  tumor,  if  it  has  ap- 
peared above  the  falciform  process  of  the  saphenous  opening,  with  the 
hand  lying  in  the  axis  of  the  thigh,  presses  it  downwards  and  a little 
inwards,  until  the  intestine  enters  the  infundibulum,  when  with  the 
fingers  of  the  other  hand  pressure  is  exercised  upward  and  a little 
outward.  Of  course,  if  the  intestine  is  found  still  in  the  infundibulum 


OF  MUSCLES  OF  THE  TRUNK. 


267 


when  the  case  is  first  seen,  the  latter  part  of  this  movement  is  only 
required,  that  is,  pressure  upwards  and  a little  outwards. 

Crural  hernia  requires  more  caution  in  manipulating  the  reduction 
than  the  inguinal,  in  consequence  of  the  firm  and  resisting  nature  of 
the  fibrous  barriers  through  which  the  intestine  passes  to  the  exterior; 
and  more  injury  is  therefore  likely  to  follow  the  efforts  to  force  it  in 
a retrograde  direction.  For  this  reason  the  time  employed  in  making 
the  taxis  should  be  much  shorter. 

From  the  shortness  of  the  omentum  and  the  lower  position  of  the 
crural  canal,  the  tumor  will  be  found  most  often  to  contain  intestine. 
When  the  reduction  has  been  accomplished,  a properly  constructed 
truss  must  be  applied. 

3.  Taxis  of  Umbilical  Hernia. — The  manipulations  required  to  re- 
turn the  extruded  intestine  in  this  variety  of  rupture  are  much  more 
simple  and  less  dangerous  than  in  either  of  the  two  preceding  varieties, 
for  the  reason  that  the  point  of  issue  is  a simple  aperture  in  the  ab- 
dominal walls  instead  of  a canal  with  sharp  and  resisting  boundaries. 

Umbilical  hernia  occurs  most  frequently  after  birth,  the  aperture 
through  which  the  vessel  of  the  child  passes  to  gain  admission  into 
the  abdomen  not  being  closed ; in  the  adult,  it  happens  in  a majority 
of  cases  in  obese  subjects. 

In  employing  the  taxis,  the  surgeon  takes  the  tumor  in  the  palm  of 
his  right  hand,  and,  having  diminished  its  size  by  compressing  it,  with 
the  fingers  of  the  other  hand  at  the  umbilicus  he  makes  compression 
directly  backwards,  until  he  may  have  effected  the  return  of  the  con- 
tents of  the  hernia.  If,  from  the  size  of  the  tumor  or  other  causes,  the 
bowel  has  descended  below  the  umbilical  ring,  pressure  will  have  to 
be  made  upwards  and  then  backwards.  When  the  reduction  has  been 
effected,  one  of  the  trusses  already  described  must  be  applied. 

Loss  of  Function  of  the  Sphincter  Ani.  Prolapsus  Ani. — This 
prolapse  occurs  both  in  infancy  and  in  the  adult,  the  former  variety 
being  much  more  amenable  to  treatment  by  mechanical  means  than  the 
latter.  It  consists  in  its  mildest  form  of  the  extrusion  of  the  rectal 
mucous  membrane  beyond  the  sphincter,  forming  a globular  shaped 
and  transversely  corrugated  tumor ; in  cases  of  long  standing,  not 
only  the  mucous  membrane  but  the  muscular  walls  of  the  gut  itself 
become  prolapsed.  In  a case  now  under  my  treatment  this  condition 
of  things  exists,  accompanied  with  so  great  a relaxation  of  the  sphinc- 
ter ani  that  the  whole  hand  can  be  introduced  into  the  rectum  with 
ease. 

Replacement  of  the  Prolapse. — In  the  first  class  of  cases  mentioned, 
or  those  occurring  in  infancy,  the  reduction  is  easily  accomplished  by 
simply  oiling  the  index  finger  and  pressing  upon  the  centre  of  the 
tumor,  when  the  bowel  will  gradually  recede  within  the  sphincter.  In 
large  prolapses,  when  the  above  plan  will  not  succeed,  the  patient  may 
be  placed  upon  his  knees  with  the  head  supported  by  a pillow  so  as 
to  give  the  pelvis  a greater  elevation  than  the  rest  of  the  body,  and  in 
order  that  the  abdominal  viscera  may  gravitate  towards  the  diaphragm; 
then  the  surgeon,  having  washed  the  tumor,  greases  the  ends  of  his 
first  three  fingers,  places  their  tips  upon  the  centre  of  the  tumor,  and 


268  APPARATUS  FOR  REMEDYING  LOSS  OF  FUNCTION 

presses  the  bowel  within  the  sphincter ; or  the  patient  may  be  placed 
upon  his  side  with  the  thighs  drawn  up  and  the  body  flexed  forwards 
so  as  to  relax  the  abdominal  muscles,  and  anaesthetized,  when  the  above 
manipulation  with  the  fingers  may  be  practised. 

Retentive  Apparatus. — The  simplest  form  of  a mechanical  support 
that  can  be  employed  in  mild  cases  of  prolapse  is  to  place,  after  the 
reduction  of  the  bowel,  a slightly  convex  pad  over  the  sphincter,  of 
sufficient  size  to  extend  beyond  its  margins,  and  secured  by  a T band- 
age. Some  surgeons  recommend  the  introduction  into  the  rectum  of 
an  ivory  or  wax  pessary  to  support  the  folds  of  its  mucous  membrane 
until  they  gain  sufficient  tone  to  resist  extrusion. 

Fig.  173.  Fig.  174. 


Apparatus  for  prolapsus  ani. 


A more  elegant  method  of  making  compression  upon  the  sphincter 
is  with  an  apparatus  (Fig.  174)  consisting  of  a well-padded  belt  for  the 
loins,  from  the  centre  of  which  belt  there  projects  posteriorly  a flat 
spring  bearing  at  its  extremity  a slight  convex  pad  firmly  stuffed  with 
fine  sand  and  covered  with  smooth  buckskin,  or  a metallic  plate  with 
an  India-rubber  air-pad  secured  upon  its  upper  surface  of  sufficient 
size  to  repose  upon  the  margins  of  the  sphincter. 

In  the  inveterate  case  above  mentioned,  under  my  care,  I employed 
an  apparatus  composed  of  a loop  of  No.  6 wire,  four  inches  long,  and 
curved  to  fit  the  anterior  surface  of  the  sacrum,  having  a stem  at  its 
base  an  inch  and  a half  long,  and  formed  of  the  two  wires  of  the  loop 
twisted  together.  The  end  of  this  stem  was  soldered  to  a wire  frame 
consisting  of  a single  wire  crossing  the  perineum  antero-posteriorly, 
and  dividing  in  front  and  behind  into  two  branches  terminating  in 
large  eyes,  through  which  a cord  was  passed  to  secure  the  apparatus 
to  the  person.  By  this  means  the  bowel  was  retained  in  its  normal 
situation  during  defecation,  by  the  instrument  holding  the  posterior 
wall  of  the  rectum  against  the  curve  of  the  sacrum. 

Loss  of  Function  of  the  Uterine  Ligaments  and  Vaginal 
Walls.  Prolapsus  Uteri. — There  are  two  kinds  of  mechanical 
supports  employed  for  the  correction  of  prolapse  of  the  uterus:  the 
one  internal,  designated  pessaries,  a name  derived  from  the  Greek 
rtEsoo,  and  supposed  by  some  to  come  from  ttteouv,  “to  assuage."  by 
others  from  rffoxo?,  the  skin  of  an  animal  with  hair  upon  it,  in  which 
the  materials  of  a pessary  were  formerly  inclosed  before  being  intro- 


OF  MUSCLES  OF  THE  TRUNK. 


269 


duced  into  the  vagina;  the  other  external,  and  commonly  called  uterine 
supporters. 

1.  Pessaries. — In  former  times  pessaries  were  composed  of  various 
medicinal  substances,  and  were  introduced  into  the  vagina  with  a view 
of  obtaining  their  specific  effects  upon  the  mucous  membrane ; astrin- 
gent articles  being  frequently  employed  in  this  manner ; no  stress  was 
laid  upon  their  use  as  mechanical  supports ; but  at  present  they  are 
especially  designed  to  obtain  this  object,  and  are  prepared  of  such 
resisting  materials  and  of  such  volume  as  to  offer  a mechanical  ob- 
struction to  the  displacement  of  the  uterus  by  taking  points  of  support 
upon  the  vaginal  wall  and  perineum,  or  they  are  sometimes  supported 
by  the  aid  of  an  exterior  bandage.  The  material  and  shape  of  pes- 
saries have  within  the  last  two  hundred  years  undergone  innumerable 
modifications;  those  employed  at  the  present  day  are  manufactured  of 
hard  wood,  certain  of  the  metals  (gold,  silver,  steel,  iron  wire),  gutta- 
percha, gum -elastic,  sponge,  cork,  &c.  The  shape  is  equally  as  various 
— globular,  oval,  discoid,  conical,  and  horseshoe-shaped. 

Pessaries  which  take  their  points  of  support  internally. — The  instru- 
ments of  this  class  enjoy  a high  reputation  and  are  much  employed 
in  America.  A simple  pessary  of  this  class  consists  of  an  oval  or 
round  discoidal-shaped  instrument  made  of  gutta-percha  or  boxwood, 
and  perforated  in  the  centre  with  a hole  for  the  escape  of  the  men- 
strual secretions,  and  which  may  also  permit  of  impregnation  taking 
place.  This  is  introduced  into  the  vagina  by  pressing  the  pessary 
held  in  the  fingers  of  the  right  hand  vertically,  against  the  vulva 
while  the  left  index-finger  depresses  the  perineum,  and  then  bringing 
it  into  a transverse  position  by  pressing  upon  its  edge  so  that  it  may 
catch  upon  each  side  of  the  vagina  in  the  direction  of  the  ischia.  The 
instrument  is  liable  to  three  objections:  first,  it  cannot  be  manipulated 
so  readily  by  the  female  herself;  secondly,  if  the  aperture  in  its  centre 
is  made  too  large,  the  neck  of  the  uterus  may  pass  through  it  and 
become  strangulated  (the  latter  objection  may,  however,  be  easily 
remedied  by  having  the  hole  made  too  small  for  this  part  of  the 
uterus  to  pass);  thirdly,  it  is  supported  by  a narrow  band  of  the 
vagina,  and  is  therefore  easily  displaced. 

Zwanck,  of  Hamburg,  has  successfully  overcome  these  objections 
by  a discoid  pessary  composed  of  two  hollow  and  oval  pieces  of  metal, 
united  by  a hinge  which  is  moved  by  a curved  stem  connected  with 
each  disk.  The  instrument  is  introduced  closed ; then  by  bringing 
the  two  stems  together,  and  fixing  them  by  a screw  at  their  extremities, 
the  disks  are  expanded.  This  pessary  is  well  adapted  to  the  severer 
cases  of  prolapse. 

Cloquet  employed  what  he  denominated  an  elvtroid  pessary,  pre- 
! pared  in  exact  imitation  of  a model  of  the  vagina,  with  the  uterus  in 
its  normal  position,  taken  with  plaster  of  Paris.  The  instrument  has 
a compressed  cylindroidal  form,  concave  anteriorly  and  convex  pos- 
teriorly, to  fit  exactly  the  curve  of  the  sacrum.  Its  upper  extremity 
is  concave,  with  its  longest  axis  transverse;  its  lower  expands  laterally 
into  two  wing-shaped  processes ; a canal  runs  its  entire  length,  to  give 


270  APPARATUS  FOR  REMEDYING  LOSS  OF  FUNCTION 


issue  to  the  menses.  It  is 
supported  in  the  vagina  by 
the  expanded  lower  extremity 
catching  upon  the  inner  sur- 
face of  that  canal  above  the 
labia  majora. 

An  elegant  form  of  pessary, 
now  coming  into  general  use 
and  possessing  many  advan- 
tages, consists  of  a ball  of 
India-rubber  connected  with 
a tube  of  the  same  material 
about  six  inches  long.  This 
instrument  (Fig.  175)  is  first 
emptied  of  air  by  pressing  it 
in  the  hand,  then  introduced 
into  the  vagina  and  inflated 
by  means  of  a second  ball,  of 
somewhat  larger  dimensions, 
also  of  India-rubber;  the  air  is  prevented  from  issuing  again  by 
closing  a little  stopcock  at  the  end  of  the  tube. 

The  shape  of  the  pessary  may  be  varied,  as  may  be  seen  in  Figs. 
176,  177,  and  178,  and  constructed  with  a central  canal  for  the  issue 

Fig.  176.  Fig.  177.  Fig.  178. 


Different  forms  of  India-rubber  pessaries. 

of  the  menstrual  secretions ; but  as  it  is  intended  that  the  ball  should 
be  removed  every  night  and  cleansed,  very  little,  if  any,  advantage  is 
obtainable  from  these  modifications. 

The  India-rubber  ball,  presenting  a large  surface,  comes  in  contact 
with  a greater  area  of  the  vaginal  walls,  and  therefore  is  better  sup- 
ported by  them,  than  any  other  kind  of  pessary. 

The  softness  and  elastic  nature  of  this  material  certainly  produce 
the  minimum  amount  of  irritation  that  any  instrument  of  the  kind 
is  capable  of  causing.  An  additional  advantage  is  also  presented  in 
that  the  patient  herself  can  introduce  and  remove  the  pessary  when- 
ever she  chooses,  for  vaginal  ablutions,  which  should  be  sedulously 
practised  every  day,  to  prevent  the  lodgment  of  acrid  or  irritating 
secretions,  or  for  other  purposes ; there  is  no  danger  of  her  giving  it 
a false  position,  nor  does  it  require  any  skill  to  put  the  pessary  in  its 
proper  place,  two  important  circumstances  which  confer  upon  it  a 


Fig.  175. 


Mode  of  introducing  the  India-rubber  pessary. 


OF  MUSCLES  OF  THE  TRUNK. 


271 


decided  superiority  over  other  instruments.  It  is  particularly  adapted 
to  prolapsus  of  the  third  degree,  when  there  is  a large  vagina  and 
much  relaxation  of  the  surrounding  parts. 

M.  Diday  employed  this  instrument  successfully  in  plugging  the 
vagina  in  uterine  hemorrhage.  Its  advantages,  according  to  him,  are: 
‘•1.  In  its  simplicity,  and  the  rapidity  with  which  it  may  be  employed. 
Thus,  it  only  weighs  about  half  an  ounce,  is  soft  and  flexible,  admit- 
ting of  being  put  in  the  instrument-case,  and  is  applied  in  a few 
seconds.  2.  It  causes  no  pain,  either  during  or  after  its  application, 
and  requires  no  bandage  to  retain  it.  3.  It  admits,  before  insufflation, 
of  being  moulded  on  the  parts  to  be  compressed,  and  thus  can  exert 
compression  upon  a cavity,  however  irregular  in  form.  4.  It  allows  of 
any  degree  of  diminution  or  increase  of  pressure  to  be  made,  according 
to  the  exigencies  of  the  case.  5.  It  is  impermeable  to  and  incor- 
ruptible by  whatever  discharges  it  comes  into  contact  with,  and  never 
loses  its  elasticity.  6.  Distended  only  to  a third  or  fourth  of  its 
natural  extensibility,  it  is  just  as  smooth,  and  possesses  nearly  as  great 
a resisting  power,  as  when  fully  distended.  7.  A somewhat  larger 
apparatus  would  be  available  for  plugging  the  cavity  of  the  uterus 
itself,  in  hemorrhage  after  delivery.  Moulded  on  the  inner  surface 
of  that  organ  during  its  state  of  inertia,  as  this  became  recovered 
from,  the  air  would  be  gradually  let  out,  and  the  size  of  the  compress- 
ing vessel  diminished  pari  passu  with  that  of  the  uterine  cavity.” 

Dr.  Hodge,  of  Philadelphia,  recommends  a pessary  composed  of 
gutta-percha,  and  shaped  as  seen  in  the  figure  (Fig.  179).  One  of  the 
shorter  sides  is  introduced  behind  the  cer- 
vix uteri  when  the  instrument  is  placed 
in  the  upper  part  of  the  vagina.  From 
the  peculiar  shape  of  the  lateral  sides 
(that  of  the  Italic  letter  s),  the  instru- 
ment is  stated  by  him  to  possess  the 
power  of  a lever,  and,  besides  supporting 
the  uterus,  throws  the  fundus  forwards, 
should  it  be  displaced  in  retroversion. 

Before  the  pessary  is  introduced,  it  must 
be  well  oiled ; and  the  forefinger  of  the 
left  hand  of  the  surgeon  being  placed 
upon  the  fourchette,  to  depress  the  peri- 
neum, the  instrument,  held  in  the  right  hand,  is  presented  to  the  vulva 
by  one  of  its  narrow  ends,  its  width  corresponding  with  the  antero- 
posterior axis  of  the  vulva,  and  is  pressed  gently  in  the  vagina,  and 
then  twisted  upon  itself  a quarter  of  a circle,  until  it  lies  transversely 
with  its  superior  cross-piece  fairly  lodged  in  the  cul-de-sac  behind  the 
neck  of  the  uterus. 

_ Sponge  has  been  employed  as  a pessary,  and  is  either  placed  imme- 
diately in  the  vagina,  or  protected  with  a covering  of  linen  or  oiled 
silk;  its  advantages  are  cheapness,  facility  of  putting  it  in  place  by  the 
woman  herself,  and  its  immediate  expansion  supporting  the  uterus  in 
its  normal  site.  The  disadvantages,  however,  of  the  material  more 
than  counterbalance  these  advantages;  it  irritates  the  vaginal  mucous 


Fig.  179. 


272,  APPARATUS  FOR  REMEDYING  LOSS  OF  FUNCTION 

membrane,  absorbs  the  secretions,  and  in  consequence  becomes  rapidly 
foul.  If  used  at  all,  it  must  be  restricted  to  slight  cases  of  displace- 
ment, and  must  be  removed  every  twelve  hours  to  be  thoroughly 
soaked  in  hot  water  and  cleansed ; two  or  three  pieces  of  the  sponge 
may  be  thus  used  alternately. 

Bauhin  employed  pessaries  of  silver  wire,  and  Prunel  those  of 
iron  wire  made  in  the  shape  of  the  frustrum  of  a cone,  and  rendered 
elastic  by  a series  of  superficial  rings  joined  together,  and  covered 
with  soft  leather.  M.  Mayor  extemporized  pessaries  consisting  of  a 
framework  of  iron  wire,  covered  with  carded  cotton  and  oiled  silk. 

Pessaries  which  are  supported  by  an  external  bandage. — One  of  the 
oldest  forms  of  this  class  of  pessaries  is  the  common  bilboquet,  which 
is  an  instrument  shaped  at  its  superior  extremity  to  receive  the  cervix 
uteri,  and  terminating  below  in  a stem  to  which  is  attached  the  straps 
to  be  fastened  above  to  a pelvic  belt.  This  method  of  supporting  a 
pessary  is  liable  to  the  objection  that  the  movements  of  the  patient 
displace  more  or  less  the  pelvic  belt,  and  thus  urge  the  instrument 
against  the  os  uteri. 

This  pessary  may  be  still  further  modified  by  constructing  the 
stem  hollow,  so  that  the  menstrual  and  mucous  secretion  may  escape 
externally. 

An  apparatus  (Fig.  180),  constructed  by  M.  Gariel,  deserves  to  be 
especially  mentioned ; it  is  intended  for  severe  cases  of  prolapse, 

attended  with  rupture  of  the  recto- 
vaginal septum,  when  some  external 
support  becomes  indispensable.  It 
consists  of  an  India-rubber  pessary 
(c),  fixed  to  the  middle  of  a perineal 
band,  which  is  supported  in  place  by 
four  thigh-straps  (b,  b,  b,  b),  formed  of 
rubber  tubes  fastened  to  a pelvic  band. 
An  aperture  is  made  in  the  perineal  strap,  that  the  patient  may  mic- 
turate without  displacing  the  bandage. 

These  forms  of  the  pessary  are  sometimes  employed  in  connection 
with  a broad  abdominal  bandage. 

2.  Uterine  Supporters. — In  Europe,  the  tendency  is  to  do  away  with 
internal  uterine  support  in  prolapse,  and  to  substitute  compression,  with 
a bandage  upon  the  sacrum,  hypogastrium,  or  perineum.  Dr.  West 
remarks,  in  regard  to  instruments  of  this  class : “ One  source  of  comfort 
to  the  patient,  from  the  employment  of  some  external  supports,  is  de- 
rived from  the  counter-pressure  on  the  pelvis  which  the  belt  exercises, 
and  Avhich  relieves  very  many  of  the  painful  sensations  experienced 
in  cases  of  uterine  prolapsus.  The  bandages  which  seem  to  me  ex- 
tremely well  adapted  for  this  purpose  are  Hull’s  utero-abdominal 
supporter,  and  a bandage  known  by  instrument-makers  as  Dr.  Ash- 
burner’s  bandage.  Each  of  them  tightly  embraces  the  hips,  while 
the  former  is  furnished  with  a large  padded  metallic  plate  fitting  over 
the  pubis,  and  the  latter  with  a similar  one  adapted  to  the  upper  part 
of  the  sacrum.  The  chief  utility  of  these  metallic  plates  is  that  by 
their  firm  and  yet  gentle  counter-pressure  they  relieve  the  sympa- 


Gariel  pessary. 


OF  MUSCLES  OF  THE  TRUNK. 


273 


tress  in  the  region  of  the  ovaries  in  another.  To  both  of  them  a strap 
passing  between  the  legs,  with  a perineal  pad,  is  adapted;  and  though 
it  can  be  dispensed  with  at  pleasure,  will  be  found  of  great  service  in 
all  cases  of  considerable  relaxation  of  the  vagina,  with  disposition  to 


Fig.  181. 


Uterine  supporter. 


Fig.  182. 


Front  and  back  view. 


actual  procidentia,  when  used  either  alone  or  in  combination  with 
some  form  of  internal  support.  The  strap  and  perineal  pad  have  the 
disadvantage  of  heating  the  parts,  and  thus  of  keeping  up  leucorrhoeal 
discharge;  but  without  them  the  instrument  cannot  be  so  well 
adjusted.  Of  the  two,  that  of  Dr.  Ashburner,  with  its  sacral  pad,  has 
seemed  to  me  the  more  useful,  greatly  relieving  the  back-ache,  and 
being  found,  indeed,  by  some  persons,  almost  indispensable  to  their 
comfort  in  walking  or  making  any  kind  of  exertion.” 

In  the  apparatus  seen  in  Fig.  183,  the  pad  is  constructed  with  a mova- 
ble plate  and  ratchet  arrange- 
ment, controlled  by  a key,  so  that 
the  pressure  may  be  graduated 
to  the  necessities  of  each  case. 

The  two  lateral  metallic  springs, 
attached  to  the  plate,  are  fast- 
sued  behind  by  strap  and  buckle. 

A.  much  simpler  supporter  may 
be  constructed  after  the  manner 
if  “Hood’s  Truss,”  already  de- 
scribed ; the  anterior  pads,  which 
ire  to  rest  above  the  pubis,  however,  should  be  larger  than  in  that 
nstrument. 

Introduction  of  Pessaries. — We  have  cursorily  glanced,  under  the 
description  of  each  instrument,  at  the  method  of  introduction  required 
by  its  individual  peculiarities;  and  therefore  a few  general  remarks, 
ipplicable  in  these  respects  to  all  of  them,  will  be  required  in  this 
place. 

■ The  position  that  a patient  should  take  while  a pessary  is  being 


Fig.  183. 


274  APPARATUS  FOR  REMEDYING  LOSS  OF  FUNCTION 

introduced,  may  be  one  of  recumbency  upon  the  back  or  left  side, 
with  the  legs  flexed  and  the  thighs  drawn  up  so  that  the  abdominal  . 
muscles  shall  be  placed  in  a state  of  the  most  perfect  relaxation  pos- 
sible. Then  the  uterus  having  been  pressed  into  its  natural  site,  the 
surgeon  greases  the  pessary  thoroughly,  and  gently  presses  it  into  the 
vulva,  and  as  high  up  into  the  vagina  as  the  cul-de-sac  behind  the 
os  uteri,  where  it  is  retained,  if  of  the  proper  size,  by  the  contractile 
power  of  the  vagina  alone.  From  an  unusual  sensitiveness  or  irrita- 
bility of  the  part,  a sufficiently  large  instrument  cannot  be  introduced 
at  first;  but  one  of  smaller  dimensions  will  have  to  be  selected  and 
used  until  the  canal  becomes  accustomed  to  its  presence,  when  it  may 
be  replaced  by  a still  larger  one.  Injections  and  the  hip-bath,  with 
rest  in  the  recumbent  posture,  will  materially  aid  in  enabling  the 
parts  to  tolerate  the  foreign  body.  Inflammation,  or  any  considera- 
ble congestion  of  the  uterus,  will  contraindicate  its  employment  until 
those  have  been  controlled  by  appropriate  medication. 

When  the  pessary  has  been  put  in  the  position  intended,  the  patient 
should  be  directed  to  move  about  the  room  and  to  cough,  in  order 
to  ascertain  if  it  will  remain  fixed,  and  does  not  cause  pain  or 
uneasiness. 

The  instrument  sometimes  causes  difficulty  in  urination  or  defeca- 
tion, numbness  of  the  legs,  or  some  pain  or  unpleasant  sensation  in 
the  small  of  the  back,  requiring  the  instrument  to  be  changed  for 
another,  and  the  use  of  emollient  injections. 

Pessaries,  prepared  of  any  material  whatever,  should  not  be  kept  for 
many  days  together  in  the  vagina,  as  a calcareous  deposit  will  take  place 
upon  their  surface,  producing  much  irritation  and  even  ulceration  of  the 
surrounding  parts,  and  they  have  been  known  to  establish  both  vesico- 
vaginal and  recto-vaginal  fistulre.  Daily  ablutions  will  diminish  in  a 
measure  this  incrustation,  and  prevent  the  accumulation  of  fetid  secre- 
tions. In  some  patients  they  may  require  removal  and  washing  every 
twenty  four  hours,  in  others  every  four  or  five  days  will  suffice ; in 
general  it  will  not  be  advisable  to  delay  it  beyond  the  latter  period. 

Should  the  tone  of  the  vaginal  walls  and  uterine  ligaments  be  re- 
stored, and  a cure  of  the  prolapse  deemed  secure,  it  will  be  requisite 
to  decrease,  by  degrees,  the  size  of  the  instrument,  and  then  gradually 
abandon  its  use. 

The  removal  of  a pessary  is  accomplished  by  placing  the  female  in 
the  same  position  as  we  have  stated  for  its  introduction,  and  then  with 
the  finger  it  may  be  hooked  and  drawn  out;  or  the  loop  of  a cord 
may  be  passed  over  some  part  of  it  and  used  as  a means  of  traction. 

SECTION  III. 

APPARATUS  FOR  REMEDYING  LOSS  OF  FUNCTION  OF  PARTS  OF  THE 
UPPER  EXTREMITIES. 

Loss  of  Function  of  Muscles  of  Fingers.  — Writer’s  cramp 
sometimes  called  chorea  scriptorum,  consists  in  a spasmodic  action  o? 
the  flexor  muscles  of  the  thumb  and  fingers,  which  either  contrac-1 
rigidly  or  irregularly  in  such  a manner  that  a pen  cannot  be  controlled 


OF  PARTS  OF  THE  UPPER  EXTREMITIES. 


275 


in  writing,  though  in  all  other  movements  in  which  the  muscles  partici- 
pate no  difficulty  from  this  source  is  encountered.  Sometimes  the 
extensor  muscles  suffer  instead  of  the  flexor.  This  spasmodic  action 
i is  seen  also  in  other  muscles  which  are  directly  employed  in  any  par- 
ticular manner,  as  those  of  the  leg  in  turning  the  lathe,  and  those  con- 
cerned in  guiding  the  needle  in  sewing,  printing,  fingering  musical 
instruments,  &c. 

Treatment. — -Absolute  abstinence  from  the  exciting  causes  is  the  only 
means  necessary  in  certain  cases  to  effect  a cure,  while  others  are  per- 
sistent for  weeks  or  months,  or  lastly,  others  again  may  be  incurable. 
The  chances  of  recovery  are  greater  or  less  in  proportion  to  the  num- 
ber of  muscles  affected,  as,  for  instance,  where  it  affects  only  those  of 
the  thumb  or  of  a single  finger.  More  hope  of  alleviation  may  also 
he  entertained  from  the  means  employed  in  these  cases  where  the  move- 
ments habitually  executed  require  the  co-ordination  of  fewer  muscles 
to  execute  them ; the  hand  of  a shoemaker  or  printer  may  be  relieved 
by  mechanical  appliances,  which  will 
enable  them  to  resume  their  avocations ; 
while,  on  the  contrary,  the  same  amount 
of  spasmodic  action  in  the  hand  of  a 
musician  could  not  be  sufficiently  di- 
minished by  the  same  apparatus  to 
enable  him  to  pursue  his  profession. 

The  mechanical  apparatus  which  have 
been  suggested  for  the  alleviation  or 
cure  of  this  remarkable  spasmodic  ac- 
tion of  the  muscles  of  the  hand  in  the 
classes  of  persons  above  mentioned  are 
ingenious.  Velpeau  invented  one  (Fig. 

184)  consisting  of  an  ovoid  handle  to 
which  is  attached  a tube  for  carrying  the  pen,  and  two  metallic  rests 
for  the  index  and  middle  fingers. 

In  mild  cases,  the  little  instrument  seen  in  Fig.  185  will  be  of  essen- 
;ial  service  in  restraining  the  abnormal  contraction  of  the  muscles.  It 


Fig.  184. 


Velpeau’s  apparatus  for  writer’s  cramp. 


Fig.  185. 


Fig.  186. 


Apparatus  for  writer’s  cramp. 


s simply  a pen  holder  supported  between  the  rings  A A fitting  on  the 
mdex  finger  and  the  thumb-piece  B. 

To  relieve  the  muscles  of  the  thumb  entirely,  the  pen  may  be  sup- 


276  APPARATUS  FOR  REMEDYING  LOSS  OF  FUNCTION 

ported  by  the  index  and  middle  fingers  only.  This  may  be  conveni- 
ently effected  with  the  contrivance  seen  in  Fig.  186 ; it  resembles  the 
frame  of  a pair  of  spectacles,  the  rings  of  which,  c c,  fit  over  the  tips  j 
of  the  index  and  middle  fingers ; between  them  there  is  a third  ring  » 
to  support  the  pen  which  is  clamped  in  it  by  the  thumb-screw  D. 

Others  have  endeavored  to  antagonize  the  muscles  by  springs  and  ; 
India-rubber  cords,  or  to  restrain  their  abnormal  action  by  making 
pressure  upon  them  Avith  a sort  of  mitten  woven  of  rubber  and  silk. 
The  same  result  may  be  obtained  by  two  accurately  moulded  splints  i 
to  the  radial  and  ulnar  sides  of  the  hand  and  connected  together  by 
an  elastic  band. 

Cazenave  invented  an  apparatus  consisting  of  a penholder  armed 
with  two  compressing  screws,  and  two  circles  of  India-rubber,  each 
provided  with  a return  screw. 

In  the  absence  of  more  perfect  apparatus,  relief  will  be  derived  from 
simply  fixing  an  ordinary  penholder  upon  the  fingers  with  a ribbon. 

Sometimes  continuous  pressure  exercised  upon  the  arm  by  a laced 
bandage  will  be  followed  by  an  alleviation  of  this  distressing  disease. 

Loss  of  Function  of  the  Interossei  Muscle  of  the  Fingers.— 

A result,  sometimes  observed  of  the  action  of  lead  poison,  or  of  some 
injury,  is  to  cause  a paralysis  of  the  interossei  muscles  of  the  fingers, 
which  then  assume  that  peculiar  position  which  has  been  called  by 
French  surgeons  “main  au  grille.”  The  first  phalanges  are  extended 
upon  the  metacarpal  bones,  by  the  common  extensor  not  being  antago- 
nized, while  the  second  and  third  phalanges  are  drawn  down  or  flexed 
upon  the  first  in  such  a manner  as  to  resemble  the  claw  of  a bird. 

After  the  removal  of  the  cause,  whatever  that  may  be,  upon  which 
this  disease  depends,  by  appropriate  medication,  electrization,  &c.,  the 
restoration  of  the  functions  of  the  affected  muscles  may  be  materially 
assisted  by  mechanical  means. 


Fig.  187. 


For  this  purpose  M.  Duchenne  has  invented  the  following  very  in- 
genious piece  of  mechanism  (Fig.  187). 

A metallic  stem  is  secured  to  the  anterior  surface  of  the  forearm  by 
a laced  wristlet,  c,  its  lower  extremity  is  articulated  to  a plate  B,  fitted  to  t 
the  palm,  by  a joint  F,  admitting  lateral  motion  only ; a second  metallic  I 


OF  PARTS  OF  THE  UPPER  EXTREMITIES. 


277 


(plate  A,  with  four  grooves,  is  jointed  to  the  first  with  ginglymoid  motion, 
and  intended  to  be  applied  to  the  palmar  aspect  of  the  fingers,  to  which 
it  is  fastened  by  a strap  passing  across  their  dorsal  surface.  To  the 
lower  edge  of  this  piece  a spiral  spring  D is  attached  by  one  of  its  ends ; 
the  other  end  has  a gut  cord  fastened  to  it,  which,  after  running  through  a 
hole  in  the  top  of  a metallic  pin  little  more  than  an  inch  long,  and  erected 
upon  the  palmar  plate,  passes  through  a ring  near  the  articulation  at 
the  wrist,  and  is  then  reflected  to  the  lower  radial  corner,  G,  of  the  second 
plate,  to  be  tied  to  a hole  placed  there  for  this  purpose.  From  the  outer 
border  of  the  palmar  plate  two  metallic  stems  also  project,  and  are  each 
supplied  with  a spiral  spring  H,  i,  and  a catgut  cord,  the  latter  intended 
to  be  fastened  to  two  little  buttondike  projections  placed  respectively 
upon  the  posterior  and  anterior  aspects  of  the  upper  portion  of  the 
wristlet.  The  action  of  the  apparatus  is  simple ; the  articulation  of 
the  wrist-stem  with  the  palmar  plate  keeps  the  hand  extended,  and  per- 
mits abduction  and  adduction  to  be  exercised  by  the  two  lateral  springs 
and  gut  cords.  The  second  or  digital  plate  serves  the  purpose  of  a splint 
in  keeping  the  fingers  straight,  and  permits  their  flexion  by  its  move- 
able  connections  with  the  palmar  piece,  and  is  under  the  control  of 
the  spring  and  cord  passing  over  the  pulley  in  the  palm. 

Loss  of  Function  of  the  Extensor  Communis  Digitorum. — 
Paralysis  of  the  common  extensor  of  the  fingers  sometimes  results  from 
ike  impregnation  of  the  system  with  lead,  and  is  characterized  by  the 
inability  of  the  patient  to  extend  the  first  row  of  phalanges  upon  the 
Metacarpus ; the  flexors  of  the  fingers  being  unopposed  contract,  some- 
limes  so  energetically  as  to  produce  almost  a subluxation  of  the  meta- 
jarpo-phalangeal  articulations.  As  shown  in  wrist-drop,  if  the  disease 
las  been  of  long  standing  and  the  muscles  atrophied,  very  little  benefit 
;an  be  expected  from  any  plan  of  treatment,  either  therapeutical  or 
nechanical.  A number  of  apparatus  have  been  suggested  by  surgeons 
o remedy  this  distressing  condition.  Of  these  none  possess  more 
nerit  than  the  one  employed  by  that  ingenious  and  learned  physician 
d.  Duchenne,  of  Boulogne  (Fig.  188),  constructed  after  the  model  of  an 


Fig.  188. 

D 


pparatus  originally  devised  by  M.  Delacroix,  and  described  by  M. 
jerdy.  It  is  composed  of  a laced  wristlet,  to  which  is  attached  a me- 
illic  plate  A,  fitting  the  posterior  and  lower  part  of  the  forearm;  to  the 
iferior  extremity  of  this  another  plate,  B,  is  articulated  by  a joint  H, 


278  APPARATUS  FOR  REMEDYING  LOSS  OF  FUNCTION 


working  laterally,  moulded  to  the  dorsum  of  the  hand,  and  secured  by 
a strap  crossing  the  palm ; to  make  it  lighter  and  to  permit  the  in- 
sensible perspiration  to  escape,  three  fenestras  are  made  parallel  with 
its  length.  Four  short  stems,  somewhat  raised  from  the  fingers,  are 
soldered  to  the  lower  edge  of  the  dorsal  plate,  furnished  with  little 
pulleys  over  which  gut  cords  d play,  connected  at  one  extremity  to  spiral 
springs  c attached  to  the  plate,  and  at  the  other  to  four  little  rings  e en- 
circling the  fingers  at  the  second  phalangeal  joints.  Two  other  spiral 
springs,  f,  are  fixed  to  the  forearm  plate,  and  continued,  by  means  of  two 
cords  passing  through  a bracket  soldered  to  its  lower  radial  corner, 
to  two  rings,  G,  placed  around  the  thumb.  If  the  extensors  and 
flexors  of  the  hand  are  intact,  a joint  may  be  placed  in  front  of  the 
articulation  at  the  wrist,  so  that  the  hand  may  be  extended  and  flexed 
by  the  action  of  those  muscles.  The  action  of  this  contrivance  is  to 
assist  the  paralyzed  common  extensor  of  the  fingers  and  the  extensors 
of  the  wrist. 

Loss  of  Function  of  the  Extensors  of  the  Hand. — Paralysis 
of  the  extensor  muscles  of  the  hand  is  most  commonly  observed  in 
painters,  and  those  who  use  lead  paints.  It  results  from  the  poisonous 
influence  of  that  metal  when  intromitted  to  the  system.  The  par- 
alysis is  not  confined  exclusively  to  these  muscles,  but  affects  generally 
the  common  extensors  of  the  fingers  to  a greater  or  less  extent:  the 
first  row  of  phalanges  cannot  in  consequence  be  raised  to  a level  with 
the  metacarpal  bones,  Avhile,  as  a general  thing,  the  second  and  third 
phalanges  can  be  extended.  It  should  also  be  further  remarked  that 
control  over  the  flexor  muscles  of  the  hand  may  be  to  some  extent 
impaired.  The  disease  belongs  to  the  class  of  bilateral  or  symme- 
trical affections,  yet  the  corresponding  muscles  are  not  commonly 
affected  in  an  equal  degree,  being  more  marked  upon  one  side  than 
upon  the  opposite.  The  extensors  of  the  feet  are  occasionally7  affected 
in  the  same  manner,  so  that  the  toes  drop  when  the  feet  are  raised  in 
performing  the  act  of  locomotion,  compelling  the  patient  to  step  high, 
that  the  toes  may  not  catch  against  the  ground. 

The  paralysis  is  sometimes  readily  cured  by  appropriate  medication, 
while  a considerable  number  obstinately  resist  all  treatment,  and  be- 
come permanent,  the  muscles 
undergoing  atrophy  and  de- 
generation, conditions  which 
render  a cure,  in  the  major- 
ity of  cases,  forever  hopeless. 

The  mechanical  treatment 
can  scarcely  do  more  than 
afford  some  alleviation  to 
this  distressing  condition. 
In  certain  cases  an  apparatus 
consisting  of  a laced  wristlet 
(Fig.  189)  extending  half  way  up  the  forearm,  from  the  roots  of  the 
fingers,  composed  of  slips  of  India-rubber,  will  confer  some  extent 
and  firmness  of  the  grasping  power. 


Fig.  1S9. 


Apparatus  for  paralysis  of  the  extensors  of  the  hand. 


OF  PARTS  OF  THE  UPPER  EXTREMITIES. 


279 


Loss  of  Function  of  the  Biceps  of  the  Arm. — Paralysis  of  the 
flexor  muscles  of  the  forearm,  resulting  from  traumatic  or  other 
causes,  inflicts  upon  a patient  a serious  drawback  to  the  utility  of  the 
upper  extremity  in  the  pursuit  of  his  avocation. 

The  functions  of  this  muscle  may  be  temporarily  supplied  by 
mechanical  means,  which  will  at  the  same  time  promote  ultimate 
restoration  of  the  limb  by  enabling  the  patient  to  exercise  the  injured 
muscle — a condition  requisite  to  the  re-establishment  of  its  healthy 
tone. 

The  apparatus  (Fig.  190)  for  this  purpose  is  very  simple,  consisting 
of  two  padded  straps  to  embrace  respectively  the  arm  and  forearm, 
and  connected  together  by  two  laternal  metallic  bars  jointed  at  the 
elbow;  a padded  plate  extends  between  the  joints  posteriorly  to  receive 
the  olecranon,  and  to  offer  a solid  resistance  to  the  displacement  of  the 


Fig.  190. 


elbow  backwards  when  the  arm  is  flexed.  The  motive  power  intended 
to  supplement  the  action  of  the  biceps  muscle  is  obtained  by  using  two 
elastic  cords  placed  upon  each  side  of  the  arm  and  extending  between 
the  anterior  portions  of  the  side  levers  and  the  middle  point  of  the 
arm  strap.  These  cords,  by  their  elasticity,  flex  the  arm  after  it  has 
been  extended  by  the  voluntary  efforts  of  the  patient. 

Loss  of  Function  of  the  Scapular  Muscles. — The  large  and 
powerful  muscles  which  contribute  largely  to  retain  the  head  of  the 
humerus  in  the  glenoid  cavity — the  deltoid,  spinate,  and  scapular — may 
become  so  relaxed  as  to  permit  the  bone  to  become  dislocated  upon 
the  application  of  slight  exciting  causes,  and  when  this  condition  is 
also  associated  with  relaxation  of  the  capsular  ligament,  as  it  usually 
is,  to  a greater  or  less  degree,  the  bone  slips  from  its  socket  spontane- 
ously. The  most  obstinate  cases  of  this  kind  originate  from  paralysis 
of  the  above-mentioned  muscles  after  contusion  of  the  shoulder,  the 
humerus  becoming  spontaneously  displaced,  and  the  arm  elongated 
and  pendent.  These  muscles,  in  such  examples,  undergo  atrophic 
degeneration  ; the  deltoid,  especially,  has  been  observed  to  be  reduced 
to  almost  a membranous  condition,  scarcely  exhibiting  any  muscular 
fibres.  In  course  of  time  the  bones  and  cartilages  entering  into  the 
structure  of  the  joint  also  participate  in  the  atrophy.  These  morbid 
changes  frequently  occupy  many  months  in  running  their  course. 


280  APPARATUS  FOR  REMEDYING  LOSS  OF  FUNCTION 

Treatment. — The  proper  treatment  consists  in  combating  the  inflam- 
matory condition  of  the  constituents  of  the  joint  by  counter-irritants, 
as  blisters,  the  actual  cautery,  and  stimulating  applications,  particularly 
the  oil  of  turpentine. 

As  it  is  desirable  to  maintain  the  functions  of  the  limb  intact,  and 
yet  secure  the  retention  of  the  humerus  in  its  socket,  the  best  appa- 
ratus that  can  be  employed  is  the  following : With  gutta-percha  sheets, 
softened  in  hot  water,  make  a mould  of  the  upper  half  of  the  arm,  as 
far  as  the  acromion  process,  also  one  of  the  shoulder,  and  a small  por- 
tion of  the  chest,  connect  them  together  by  a narrow  India-rubber  rib- 
bon at  the  point  corresponding  with  the  shoulder-joint.  That  part 
of  the  apparatus  upon  the  chest  can  be  secured  by  a circular  lacing 
belt  surrounding  the  body.  By  means  of  this  arrangement  the  head 
of  the  humerus  will  be  held  in  the  glenoid  cavity,  while  the  arm  is 
being  exercised  in  its  natural  functions. 

Some  persons  have  endeavored  to  secure  the  retention  of  the  hume- 
rus by  preparing  and  applying  a solid  gutta-percha  splint  to  both  the 
upper  half  of  the  arm  and  shoulder. 

Still  a third  plan  has  been  employed  with  success.  It  requires  a 
short  crutch  to  be  placed  in  the  axilla,  supported  by  a broad  band 
passing  from  its  lower  extremity  over  the  opposite  shoulder.  A 
second  band  encircles  the  chest  and  injured  arm,  so  as  to  maintain  the 
latter  immovable. 

SECTION  I Y. 

APPARATUS  FOR  REMEDYING  LOSS  OF  FUNCTION  OF  PARTS  OF  THE 
LOWER  EXTREMITIES. 

Some  of  the  most  difficult  and  trying  cases,  to  the  surgeon,  of  loss 
of  function  of  the  muscles  and  ligaments  occur  in  the  lower  extre- 
mities, from  paralysis,  debility,  gout,  and  rheumatism,  particularly 
from  the  first-mentioned  disease,  which,  as  it  commonly  results  from 
centric  causes,  or  morbid  changes  in  the  nervous  masses  themselves, 
is  always  of  serious  import,  demanding  that  the  efforts  of  the  phy- 
sician should  be  first  directed  to  the  relief  of  these  important  struc- 
tures, upon  the  integrity  of  which  the  exercise  of  the  functions  of  the 
muscles  depends.  In  those  cases  where  the  patient  survives  the  first 
shock  of  paralytic  disease,  and  the  nervous  tissues  wholly  or  partially 
regain,  as  they  sometimes  do,  their  capacity  for  originating  or  con- 
ducting the  stimulus  of  the  will,  after  the  lapse  of  a longer  or  shorter 
time,  a great  deal  may  be  accomplished  in  furthering  the  resumption 
of  the  lost  muscular  motility,  by  having  recourse  to  suitable  mechani- 
cal contrivances,  composed  of  levers  and  elastic  cords,  to  support  the 
weight  of  the  patient’s  body,  and  to  supplement  the  lost  or  impaired 
functions,  until  the  muscles  shall  have  regained  sufficient  power  to 
execute  their  natural  offices. 

The  difficulties  in  the  mechanical  treatment  of  these  cases  will  be 
increased,  in  proportion  to  the  extent  of  the  parts  involved,  and  the 
prognosis  will  depend  upon  the  nature  of  the  cause  disabling  the 
muscles ; for  instance,  the  paralysis  of  the  tibialis  anticus,  or  peronei 


OF  PARTS  OF  THE  LOWER  EXTREMITIES. 


281 


muscle,  from  local  causes,  is  much  more  readily  and  quickly  cured  by 
suitable  apparatus  than  the  same  disease  originating  from  central  causes, 
or  changes  in  the  encephalon  or  spinal  marrow.  Most  frequently, 
it  must  be  confessed,  the  larger  proportion  of  cases  fall  into  the  latter 
category,  and  they  vary  much  in  their  severity  and  extent.  From 
some  hitherto  unexplained  cause  the  extensor  are  more  frequently 
affected  by  paralysis  than  the  flexor  muscles.  The  disease  may  involve 
the  muscles  generally,  when  the  paralysis  is  said  to  be  general,  or  may 
be  confined  to  one  limb  or  portion  of  the  body — partial  paralysis ; 
when  certain  muscles  or  groups  of  muscles  suffer,  the  paralysis  is 
said  to  be  local. 

Loss  of  Function  of  the  Tibialis  Anticus.  — Paralysis  of  the 
tibialis  anticus  is  sometimes  observed  to  be  associated  with  central 
disease  of  the  brain  and  spinal  cord,  but  the  most  marked  examples 
are  those  originating  in  impregnation  of  the  animal  economy  with 
lead.  Its  characteristic  features  are  inability  to  flex  the  foot  upon  the 
leg,  which,  in  walking,  drags  along  the  ground,  the  toes  striking  against 
every  obstacle.  The  affection  is  the  analogue  of  “drop-wrist,”  and 
has  been,  not  inappropriately,  named  “drop-foot.” 

In  club-foot  this  muscle  sometimes  becomes  so  much  elongated  that 
after  the  operation  of  section  of  the  tendo-Achillis,  it  does  not  con- 
tract, and  maintain  the  foot  in  its  normal  relation  with  the  leg,  even 
after  using  appropriate  apparatus. 

Treatment. — The  treatment  of  this  disease  consists  in  employing, 
along  with  the  therapeutical  remedies,  iodide  of  po- 
tassium, cold  douche,  electricity,  &c.,  a mechanical 
contrivance  constructed  in  the  following  manner: 

Fasten  a steel  lever,  jointed  at  the  ankle  upon  the 
inner  side  of  the  leg,  by  attaching  its  lower  extremity 
to  the  sole  of  a boot,  and  the  upper  extremity  to  a 
padded  strap  surrounding  the  leg  below  the  tubercle 
;of  the  tibia.  Solder  to  the  lever  above  the  ankle- 
joint  a curved  metallic  rod  spanning  the  instep,  and 
supporting  at  its  extremity  in  front  an  aperture 
■through  which  an  elastic  cord  passes,  connected 
below  to  the  sole  of  the  boot  near  the  toe  and  above 
to  the  leg-strap.  This  cord  serves  the  purpose  of  an 
artificial  tibialis  anticus,  and  lifts  the  toes  when  the 
oatient  is  walking,  so  that  they  do  not  strike  against 
he  irregularities  of  the  surface  over  which  he  passes, 
lor  do  they  drag  along  the  ground. 

In  the  annexed  illustration  (Fig.  191)  is  shown 
in  apparatus  which  may  be  employed  when,  besides 
he  paralysis  of  the  tibialis  anticus,  there  is  also  de- 
icient  power  in  the  extensors  of  the  leg.  The  upper 
dastic  cord  extends  the  leg  while  the  lower  one 
Raises  the  toes  during  the  time  the  patient  is  walk- 

ml  . p ° , . 1 , ,1  lysis  of  the  tibialis  an- 

ng.  ihe  rest  ot  the  apparatus  is  similar  to  the  one  ticiis. 
lescribed  above. 

Loss  of  Function  of  the  Peronei  Muscles. — The  peronei  mus- 


Fig.  191. 


282  APPARATUS  FOR  REMEDYING  LOSS  OF  FUNCTION 


cles  are  sometimes  involved,  along  with  the  tibialis  anticus,  in  para- 
lysis, and  then,  besides  being  unable  to  flex  the  foot,  the  patient  cannot 
abduct  it. 

Treatment. — This  morbid  condition  requires,  therefore,  another  form 
of  mechanism  than  the  one  previously  described  to  meet  the  necessi- 
ties of  the  case.  It  consists  of  a side-stem  articulated  below  to  the 
middle  of  a short  lever  fastened  by  its  posterior  extremity  to  a short 
upright  springing  up  from  the  heel  of  the  boot.  An  elastic  cord 
connects  the  anterior  point  of  the  lever  with  the  padded  leg-strap 
above,  and  by  its  action,  both  flexes  and  abducts  the  foot. 

Loss  of  Function  of  the  Extensor  Muscles  of  the  Legs. — 
We  have  alluded,  in  the  previous  instances,  to  paralysis  affecting 
isolated  muscles  or  a group  of  muscles  of  the  lower  extremities,  and 
the  instruments  required  for  their  treatment.  In  other  cases,  and 
indeed  the  majority  of  those  that  will  come  under  the  care  of  the 
surgeon,  the  paralysis  extends  to  most  of  the  muscles  of  both  lower 
extremities,  constituting  paraplegia;  or  it  may  be  confined  to  one  of 
them,  and  this  conjoined  with  a similar  condition  of  the  corresponding 
upper  extremity,  is  then  called  hemiplegia.  Of  course  in  all  these 
cases  pharmaceutic  medication,  friction,  galvanism,  cold  douche  are 
to  be  had  recourse  to ; and,  after  acute  symptoms,  if  there  have  been 
any  present,  have  subsided,  and  the  patient  so  far  recovered  as  to  be  in 
a suitable  condition  for  moving  about  his  room,  or  indeed  for  going  out 
into  the  open  air,  the  surgeon  should  endeavor,  by  mechanical  con- 
trivances, to  aid  the  faltering  muscles,  and  support  the  weight  of  the 
body  during  the  time  the  patient  is  exerting  himself  in  walking.  In 
this  manner  the  debilitated  or  paralyzed  muscles  will  be  stimulated 
to  contract  and  to  resume,  to  a greater  or  less  extent,  their  wonted 
vigor. 

Treatment. — The  ordinary  frame  (Fig.  192)  had  recourse  to  in  such 

cases  will  answer  quite  well 
in  sustaining  the  patient 
erect  while  he  exercises  his 
legs  in  walking.  The  frame 
consists  of  two  short  crutches 
supported  upon  and  sliding 
in  a padded  wooden  ring, 
connected  at  a convenient 
height  with  a square  frame 
borne  by  four  upright  arms 
moving  upon  castors. 

The  patient  supported  in 
this  mechanism  can,  when 
his  leg's  are  braced  with  the 
apparatus  described  below, 
propel  it  forwards  by  the 
mere  act  of  stepping. 

In  paralysis  of  a single 
lower  extremity  the  appa- 
ratus (Fig.  193)  required  to 


Fig.  192. 


Supporting  frame  for  paralysis  of  tlie  lower  extremities. 


OF  PARTS  OF  THE  LOWER  EXTREMITIES. 


283 


restore  the  lost  muscular  functions  will  consist:  1st.  Of  an  external 
lever  extending  from  a well-padded  thigh  strap  to  near  the  middle 
of  the  sole  of  the  boot,  articulated  at  the  knee  and  ankle-joints;  2d. 
An  internal  lever,  jointed  at  the  knee  and  ankle,  supported  above  by 
the  thigh-strap,  and  connected  to  the  sole  in  the  same  manner  as  the 
first  lever;  the  apparatus  is  ren- 


Fie.  193. 


Fig.  194. 


dered  still  more  firm  by  a padded 
strap  connecting  the  two  levers 
together  below  the  knee;  3d.  Two 
elastic  cords  stretching  between 
the  sole  and  the  leg-strap,  to  flex 
the  foot;  and  two  other  cords  at- 
tached below  to  a short  lever  pro- 
jecting anteriorly  from  the  knee 
articulation,  and  above  to  the 
thigh-strap  ; these  extend  the  leg 
upon  the  thigh.  To  carry  the 
whole  limb  forward  three  elastic 
' cords  are  employed,  fastened  be- 
low to  a steel  arc  spanning  across 
the  knee  and  above  to  the  pelvic 
band.  The  two  levers  are  curved 
forward  at  the  ankle  so  that  they 
may  be  attached  to  the  centre  of 
the  sole  of  the  boot,  and  thus 
facilitate  the  lifting  of  the  toes 
when  the  patient  steps  forward. 

Where  there  is  a constant  dispo- 
sition of  the  knee  to  yield  in  a 
! forward  direction  by  the  weight 
of  the  body,  I sometimes  use  an- 
other form  of  artificial  support  (Fig.  194),  in  which  the  elastic  cords 
are  discarded  and  the  knee  is  locked  by  the  metallic  rods  extending 
between  the  straps  posteriorly,  as  seen  in  the  figure. 

These  apparatus  will  be  found  efficient  in  those  cases  of  paralysis 
where  the  two  limbs  are  of  the  same  length ; in  other  instances  the 
paralysis  takes  place  during  childhood,  originating,  perhaps,  in  the 
majority  of  cases,  from  perverted  innervation  depending  upon  some 
disease  of  the  brain  or  spinal  cord;  the  development  of  the  limb  is 
arrested,  and  the  patient  grows  to  adult  age  with  more  or  less  diminu- 
tion in  its  length  and  volume.  For  such  persons  the  foregoing 
instruments  will  have  to  be  somewhat  modified  by  the  addition  of  a 
thick-soled  boot  to  render  the  limbs  uniform  in  length. 

When  the  paralysis  involves  both  lower  extremities,  a still  more 
complicated  mechanism  (Fig.  195)  will  be  demanded.  It  consists  of 
two  levers  extending  from  the  axillas  to  the  soles  of  the  boots,  pro- 
vided above  with  crutches,  and  articulated  at  the  hips,  knees,  and 
ankles.  These  are  secured  to  the  body  by  means  of  thoracic  and 
pelvic  belts,  thigh  and  leg-straps,  and  broad  bands  around  the  knees. 


Apparatus  for  paralysis  of  one  extremity. 


284.  APPARATUS  FOR  REMEDYING  LOSS  OF  FUNCTION 

The  India-rubber  cords  to  imitate  the  action  of  the  muscles  are  placed, 
as  in  the  other  instrument,  at  the  hips,  knees,  and  ankles.  This  appa- 
ratus may  be  occasionally  modified  with  advantage  by  an  arrangement 
which  will  enable  the  surgeon  to  lock  the  knee-joints  by  means  of 
metallic  rods  connecting  the  straps  upon  the  limb.  (Fig.  196.) 

In  the  beginning  of  the  treatment  of  a case  of  paralysis  of  the  lower 
extremities,  the  latter  form  of  apparatus  should  be  generally  preferred, 
as  the  patient  can  get  along  better  with  it  than  when  motion  is  per- 
mitted at  the  knee-joints ; as  it  possesses  more  stability,  he  feels  greater 
confidence,  and  will  step  out  boldly,  without  fear  of  his  knees  yielding 
beneath  him. 

After  the  patient  has  gained  some  control  over  his  limbs  the  rods 
may  be  removed  and  elastic  cords  substituted. 


Fig.  195.  Fig.  196. 


Apparatus  for  paralysis  of  both  extremities. 


Loss  of  Function  of  the  Ligaments  of  the  Knee-Joint 
(Knock-Knee,  Genu-valgum). — This  affection,  next  to  rachitic  cur- 
vature of  the  bones,  is  perhaps  the  most  common  deformity  met  with: 
it  occurs  at  any  period  of  life  from  infancy  to  adult  age,  and  is  rarely 
or  never  seen  in  vigorous  manhood  or  old  age.  It  is  never  congenital, 
and  after  infancy  is,  perhaps,  most  frequent  between  the  ages  of  ten 
and  eighteen  years.  Though  the  higher  classes  are  not  exempt  from 
its  attacks,  yet  it  is  found  chiefly  among  the  poor  and  ill-fed  classes  of 
society.  This  deformity  is  seen  in  Fig.  197. 

The  pathology  of  the  disease  has  been  shown  to  consist  in  a relaxed 


OF  PAETS  OF  THE  LOWEE  EXTEEMITIES. 


285 


condition  of  the  internal  lateral  and  posterior  crucial  ligaments  of  the 
knee-joint,  so  that  the  articulation  gains  other  than  antero-posterior 
motion,  the  only  one  it  pos- 
sesses in  its  normal  condition. 

The  leg,  when  flexed,  has  its 
ordinary  position  and  rela- 
tions ; partially  extended,  the 
tibia  rotates  obliquely  out- 
wards, and  in  full  extension, 
instead  of  being  in  a straight 
line  it  rotates  laterally,  leav- 
ing a space  between  the  inner 
condyle  and  the  head  of  the 
tibia.  It  is  believed  by  some 
pathologists  that  the  external 
condyle,  being  more  pressed 
against  than  the  internal,  is 
arrested  in  its  growth,  when 
the  disease  has  lasted  from 
infancy,  so  that  the  inner  con- 
dyle becomes  disproportion- 
ally  large  and  altered  in 
figure,  and  causes  the  oblique 
outward  rotation  of  the  tibia 
observed  to  take  place.  Mr.  Tamplin,  on  the  other  hand,  does  not  be- 
lieve that  an  actual  enlargement  takes  place,  but  that  it  is  only  appa- 
rent in  consequence  of  the  gastrocnemius  not  following  altogether  the 
position  of  the  condyle,  but  recedes  from  the  tibia  and  femur  on  the 
internal  side  and  passes  in  a more  direct  line  to  its  origin.  There  is, 
however,  an  enlargement  of  the  tubercle  of  the  tibia  sometimes  ob- 
served. 

Knock-knee  is  often  found  associated  with  rachitic  curvature  of 
the  femur  and  bones  of  the  leg,  and  sometimes  in  infancy  curvature 
of  the  leg  bones  occurs  without  this  disease,  but  after  ten  years  of 
age  this  result  never  occurs.  In  infancy,  also,  the  malposition  of  the 
limb  causes  the  astragalus  to  assume  an  oblique  position,  so  that,  with 
the  yielding  of  the  internal  lateral  ligaments  of  the  ankle-joint,  a 
spurious  talipes  valgus  is  produced ; very  rarely  a true  valgus,  with 
paralysis  of  the  tibialis  anticus  muscle,  has  been  encountered. 

One  of  the  serious  complications  of  knock-knee  is  curvature  of  the 
spine,  resulting  from  obliquity  of  the  pelvis  in  consequence  of  the 
unequal  yielding  of  the  two  legs,  which  almost  always  happens  in  the 
course  of  the  deformity ; so  that,  to  restore  the  equilibrium  of  the 
: body,  a curve  must  be  formed  in  the  spinal  column  with  its  convexity 
looking  to  the  side  with  the  longest  leg.  The  disease  is  seen  some- 
times to  affect  but  one  knee and  again,  in  rare  examples,  the  oppo- 
site knee  curves  outwards  (Fig.  198);  in  these  cases,  for  obvious  rea- 
sons, spinal  curvature  progresses  with  greater  rapidity. 

It  has  been  already  stated  that  the  predisposing  cause  to  knock- 
knee  is  debility;  the  exciting  causes  are  said  to  be  the  irritation  of 


Fig.  197. 


286  APPARATUS  FOR  REMEDYING  LOSS  OF  FUNCTION 

teething,  the  eruptive  fevers  carrying  heavy  burdens,  and  standing 
erect  too  incessantly,  as  is  required  of  youths  in  certain  factories 

during  their  hours  of 
labor.  When  the  knees 
once  begin  to  yield,  the 
weight  of  the  body,  act- 
ing to  a greater  advant- 
age upon  the  legs,  causes 
the  disease  to  progress 
with  greater  rapidity. 

Treatment. — The  treat- 
ment of  knock  knee  me- 
chanically is  attended 
with  great  success,  but  it 
should  always  be  associ- 
ated with  alteratives,  to- 
nics, nutritious  food,  and 
fresh  air,  to  obtain  speedy 
and  lasting  results. 

In  considering  the  me- 
chanism of  knock-knee 
with  a view  of  obtaining 
correct  mechanical  prin- 
ciples upon  which  to  con- 
struct our  apparatus,  we 
shall  find  that  there  has 
occurred  a deviation  in 
the  shape  of  the  limb, 
which  normally  repre- 

Knock-knee  with  outward  curving  of  the  opposite  knee.  SentS  a Vertical  Column 

supporting  the  body 
upon  its  apex  in  the  direction  of  the  line  of  its  axis,  the  extremi- 
ties and  fixed  points  of  which  are  respectively  at  the  acetabulum  and 
ankle-joint.  If  now  the  internal  lateral  and  posterior  crucial  liga- 
ments yield,  the  knees  will  move  inwards  towards  each  other,  and 
the  body  will  then  be  supported  in  the  direction  of  a broken  line 
passing  through  the  femur  and  tibia,  and  representing  two  sides  of  a 
triangle,  the  base  of  which  is  formed  by  the  normal  axis  of  the  limb, 
and  its  apex  by  the  knee-joint  itself;  the  feet,  receiving  this  -weight 
in  an  oblique  direction  outwards,  which  the  legs  have  now  assumed, 
will  be  removed  to  a greater  distance  from  each  other,  a condition 
which  is  always  observed  in  this  affection.  An  apparatus,  then,  to 
counteract  it,  should  be  a lever  running  parallel  with  the  normal  axis 
of  the  limb,  and  have  two  fixed  points  of  resistance  corresponding 
with  the  extremities  of  this  axis,  with  straps  or  other  contrivances 
acting  from  its  centre  upon  the  knee-joint  from  within  outwards;  in 
other  words,  from  the  apex  of  the  triangle  to  its  base. 

The  lever  should  not  be  jointed,  at  least  in  severe  cases ; as,  when 
it  possesses  a centre  of  motion  at  the  knee,  every  time  the  leg  is  bent 
the  apparatus  tends  to  rotate  inwards  at  the  hip,  thus  destroying  the 


Fig.  198. 


OF  PARTS  OF  THE  LOWER  EXTREMITIES.  287 

.force  of  the  bands  acting  upon  the  knee;  although  in  milder  cases,  or 
after  the  limb  has  been  straightened  by  an  inflexible  stem,  a jointed 
mechanism  may  be  employed  with  advantage.  Indeed,  an  instrument 
in  general  use  is  constructed  upon  this  plan.  It  consists  of  a lateral 
splint,  connected  above  to  a padded  pelvic  strap,  below  to  the  soles  of 
the  boots,  and  jointed  at  the  hip,  knee,  and  ankle  joints.  Two  straps 
are  affixed  to  the  stem,  one  to  the  thigh  lever,  which  passes  across  the 
popliteal  space  and  head  of  the  tibia,  to  be  buckled  to  the  leg  lever 
in  front ; another  to  the  leg  lever,  which 
crosses  the  former  in  a reverse  direction, 

,to  be  attached  to  the  stem  above  the  knee. 

By  this  arrangement  the  straps  support 
and  act  both  upon  the  head  of  the  tibia 
and  the  condyles  of  the  femur. 

Another  simple  contrivance  is  shown 
in  Fig.  199.  It  is  composed  of  two  con- 
cave splints  connected  together,  at  the 
knee,  one  fitting  the  outside  of  the  thigh, 
and  the  other  the  corresponding  surface 
of  the  leg.  The  upper  extremity  of  the 
thigh-piece  bears  a metallic  stem,  to  which 
a pelvic  strap  is  fastened ; while  the  lower 
end  of  the  leg  portion  is  attached  to  the 
sole  of  the  boot  by  a rectangular  pin  fit- 
ting into  a socket.  The  requisite  amount 
of  lateral  traction  is  obtained  by  the  cir- 
cular straps  shown  in  the  illustration,  connected  with  splints  and 
surrounding  the  limb. 

The  straps  in  these  forms  of  apparatus  do  not  secure  the  limb  to 
the  lever  with  much  firmness,  and  therefore  much  of  their  tractile 
ipower  is  lost  when  the  legs  are  being  used.  To  remedy  this  disad- 
vantage to  some  extent,  it  is  only  necessary  to  substitute  for  the 
two  knee-straps  broad  metallic  thigh  and  leg-bands,  well  padded,  and 
fastening  to  the  limb  with  narrow  leather  straps  and  buckles.  These 
bands,  with  a broad  knee-cap,  secure  the  limb  firmly,  and  answer 
;3very  requirement. 

Another  form  of  instrument  may  be  employed  in  mild  cases,  and 
worn  under  the  ordinary  garments  of  the  patient  without  being  de- 
fected. The  jointed  side-stem  is  attached  above  and  below  to  padded 
metallic  thigh  and  leg-bands,  while  the  knee  is  drawn  outwards  by  a 
oroad  webbing  knee-cap. 

In  the  formation  of  knock-knee,  the  theory  “ that  the  lower  part  of 
he  leg  (tibia  and  tarsus)  rotates  from  the  inferior  extremity  of  the 
’emur,  in  an  outward  direction,  and  that  the  thigh  always  holds  its 
Original  and  perfect  position,”  is  held  by  some  surgeons,  and  Mr.  Hes- 
■er,  of  London,  based  upon  this  view  the  construction  of  an  apparatus 
Fig.  200)  which  is  thus  described  by  Mr.  Bigg:  “It  is  constructed  of 
wo  levers,  with  a large  hollow-jointed  disk  at  their  point  of  junction, 
vhich  receives  the  internal  condyle  within  its  circumference.  Of 
hese  levers  one  corresponds  with  the  proper  line  of  the  thigh,  the 


Fig.  199. 


288  APPARATUS  FOR  REMEDYING  LOSS  OF  FUNCTION 


Fig.  200. 


Hester’s  apparatus  for 
knock-knee. 


Fig.  201. 


other  with  that  of  the  leg,  and  both  terminate  by  padded  metal  bands, 
those  above  the  thigh,  these  below  the  calf.  When  the  upper  stem  is 
fixed  firmly  to  the  thigh,  a space  is  left  between 
the  inferior  extremity  of  the  lower  stem  and  the 
internal  malleolus  of  the  tibia,  proportional,  of 
course,  to  the  angularity  of  the  limb ; which  space 
must  be  reduced  by  fastening  the  lower  padded 
band  as  tightly  as  the  patient  can  bear  it.”  He 
also  remarks  that,  “ in  the  mechanical  action  of  this 
instrument,  the  thigh-lever  becomes  a fixed  point, 
its  major  fulcrum  being  situated  at  the  inner  con- 
dyle; while,  as  the  resistance  to  be  overcome  is 
afforded  by  the  lower  leg,  the  calf-band  presents 
the  required  means  for  reducing  the  space  between 
the  tibia  and  leg-stem.  Kneeling  can  be  performed 
at  pleasure  during  the  whole  period  of  treatment, 
the  knee-disk  forming  a ring-joint.”  In  a severe 
case  treated  by  me  with  this  apparatus,  it  did  not 
afford  satisfactory  results,  and  was  abandoned; 
though  in  milder  cases,  I think,  it  would  succeed. 
An  excellent  form  of  appliance  (Fig.  201),  in  severe  cases  of  knock- 
knee,  is  constructed  with  a lateral  lever  connected  above  to  a pad- 
ded pelvic  belt,  and  below  to  the  sole  of  the 
boot;  the  stem  has  joints  at  the  hip  and 
ankles,  while,  at  the  knee,  there  is  a ratchet 
arrangement  controlled  by  a key,  by  means  of 
which  it  may  be  bent  laterally  to  conform  to 
the  outer  and  concave  sweep  of  the  limb.  To 
the  stems  are  attached  padded  metallic  thigh 
and  leg-straps  and  a webbing  knee-cap.  By  the 
gradual  extension  of  the  levers  the  knee  is 
drawn  outwards,  and  the  extremity  straight- 
ened. 

If  there  should  be  contraction  of  the  knees 
along  with  the  deformity,  the  addition  of  a 
second  ratchet-screw  to  this  instrument  at  the 
knee-joint,  acting  antero-posteriorly,  will  be  re- 
quired. Where  the  more  elaborate  apparatus 
cannot  be  obtained,  an  extemporaneous  con- 
trivance, described  by  Mr.  Tamplin,  may  be 
used.  “ A splint  made  of  two  zinc  plates,  one 
portion  to  correspond  with  the  thigh,  the  other 
with  the  leg;  there  is  a straight  piece  of  iron  or  wood  attached  by  a 
hinge  to  the  centre  of  each  of  the  portions  of  the  splint  on  the  outside. 
The  zinc,  from  being  soft,  admits  of  being  applied  close  to  the  limb, 
and  can  be  fixed  by  means  of  strapping  in  the  position  in  which  the 
joint  is ; a webbing-strap  passed  round  the  knee  and  over  the  con- 
necting piece  of  iron,  will,  by  gradually  tightening  it,  effectually 
straighten  the  limb.” 

All  forms  and  degrees  of  knock-knee  may  be  successfully  treated, 


OF  THE  HEAD  AND  NECK. 


289 


j as  far  as  mechanical  means  will  accomplish  it,  by  the  apparatus  now 
described.  There  are  cases  where  section  of  the  biceps  cruris  will 
be  required  to  insure  a satisfactory  result  before  the  apparatus  is 
applied. 

Loss  of  Function  of  the  Ligaments  of  the  Hip.— The  capsular 
ligament  of  the  hip-joint  may  become  so  relaxed  in  certain  cases  of 
children  with  feeble  constitutions  and  relaxed  habits  of  body,  that  the 
femur  gains  more  motion  than  is  compatible  with  steady  and  firm 
locomotion.  The  patient  has  a sensation  of  yielding  at  every  step,  as 
if  he  were  walking  upon  some  soft  and  yielding  surface. 

The  mechanical  expedient  for  correcting  this  unpleasant  condition 
of  things  consists  in  making  pressure  upon  the  trochanter  major  from 
behind,  forwards  and  inwards — that  is,  to  press  the  head  of  the  femur 
into  the  acetabulum.  This  may  be  accomplished  by  means  of  a 
metallic  lever  jointed  at  the  hip,  terminating  above  beneath  the 
axilla  in  a crutch,  and  below  in  a short  arm  reaching  to  the  middle 
,of  the  thigh ; this  is  connected  to  the  body  by  a pelvic  strap  and  a 
broad  webbing-band  surrounding  the  chest,  while  its  lower  end  is 
secured  to  the  thigh  by  a padded  metallic  strap.  From  beneath  the 
joint  a stem  projects  bearing  a firm  compress,  regulated  by  a screw, 
to  make  the  requisite  degree  of  pressure  over  the  trochanter.  To 
prevent  the  apparatus  slipping  around  the  hips,  an  additional  strap 
may  be  added,  passing  round  the  opposite  thigh. 


CHAPTER  III. 

APPARATUS  FOR  REMEDYING  LOSS  OF  SYMMETRY  OF  PARTS. 

SECTION  I. 

1PPARATUS  FOR  REMEDYING  LOSS  OF  SYMMETRY  OF  THE  HEAD  AND  NECK. 

Deformity  of  the  Nose. — In  fracture  of  the  nasal  bones,  this 
•rgan  may  be  bent  over  to  one  side  or  the  other  so  as  to  produce  a 
■ainful  deformity,  and  indeed  in  the  majority  of  cases  of  such  injuries 
lore  or  less  distortion  remains  either  because  patients  do  not  apply 
i the  surgeon  timely  enough  to  have  the  fracture  promptly  reduced, 
r because,  in  consequence  of  the  tumefaction  of  the  parts  the  nature 
f the  injury  remains  undiscovered  until  the  opportune  time  has  fled 
) correct  the  oversight  or  mistake.  But  even  in  instances  where  the 
ose  has  been  bent  aside  for  some  time,  continuous  pressure  will  re- 

Iress  the  organ  to  some  extent.  This  may  be  accomplished  by  means 
f a firm  pad  borne  upon  the  end  of  a metallic  stem,  moving  by  a 
itchet  arrangement,  and  sustained  in  position  by  being  connected 
ith  a padded  metallic  spring  surrounding  the  forehead.  By  the  aid 
■ a key  the  pressure  may  be  increased  or  diminished  at  pleasure  upon 
lat  side  of  the  nose  towards  which  the  bend  has  occurred. 

19 


290  APPAEATUS  FOR  REMEDYING  LOSS  OF  SYMMETRY 


Immobility  of  the  Lower  Jaw. — Immobility  of  the  lower  jaw 
originates  from  preternatural  contraction  of  the  masseter  and  tempo- 
ralis muscles,  the  formation  of  cicatricial  tissue  in  the  form  of  hands, 
or  the  establishment  of  osseous  union  between  the  jaws,  and  produces 
a painful  and  serious  deformity  in  the  configuration  and  symmetrical 
proportion  of  the  features  of  the  face.  When  of  long  duration  the 
chin  projects  beyond  the  upper  jaw,  the  lower  incisors  grow  to  an  in- 
ordinate length,  assuming  a decidedly  carnivorous  appearance.  The 
most  frequent  cause  of  this  deformity  is  the  destructive  effects  of  the 
excessive  use  of  mercurials  upon  the  lower  jaw  and  the  soft  tissues 
connected  with  it. 

Treatment. — The  mechanical  treatment  required  in  this  disease  con- 
sists in  forcibly  separating  the  jaws. 
For  this  purpose  the  instrument  of 
Scultetus  (Fig.  202),  constructed 
upon  the  principle  of  the  screw 
and  lever,  was  commonly  employed 
by  the  late  Dr.  Mott. 

Dr.  Gross,  of  Philadelphia,  re- 
gards the  instrument  exhibited  in 
the  annexed  sketch  (Fig.  203)  as 


Fig.  203. 


Lever  for  separating  the  jaws. 


Fig.  202. 


Scultetus’  lever  for  separating  the  jaws. 


Fig.  204.  superior,  as  a mere  lever,  to  that  of 

Scultetus.  It  bears  a close  resem- 
blance to  the  instrument  used  by 
Pard,  and  figured  in  his  work. 

For  the  same  purpose  Mr.  Tamplin 
used  an  instrument  fitting  the  teeth 
of  the  upper  jaw,  which  acted  as  a ful- 
crum, and  introduced  over  the  teeth 
of  the  lower  jaw  small  narrow  blunt 
steel  hooks  attached  to  the  instrument 
by  means  of  a screw ; with  this  he 
gradually  forced  the  jaws  asunder. 

An  ingenious  modification  of  this 
instrument  (Fig.  204),  and  one  much 
superior  to  it,  has  been  devised  by 
Mr.  Bigg;  it  is  composed  of  "two 
firm  but  thin  rods  of  metal  accurately 
Bigg’s  apparatus  for  separating  the  jaws.  modelled  to  the  chin  and  articulated 

at  the  point  where  the  lower  jaw  has 
its  axis  of  motion.  To  each  rod  is  fixed  a horizontal  metal  lip,  which. 


OF  THE  HEAD  AND  NECK.  291 

having  been  first  covered  with  India-rubber,  is  inserted  between  the 
lips.  By  means  of  two  vertical  screws,  fixed  at  the  angles  of  the  lips, 
the  rods  can  be  separated  from  each  other  and  the  mouth  gradually 
opened.” 

Projection  of  the  Chin. — Sometimes,  after  the  first  dentition,  but 
especially  after  the  second,  in  certain  children,  the  lower  jaw  projects 
beyond  the  upper  so  as  to  cause  an  unpleasant  prominence  of  the  chin. 

Treatment. — The  deformity  may  be  corrected  by  bringing  pressure 
to  bear  upon  the  chin  by  means  of  a sling  bandage  fastening  over  the 
occiput.  An  inclined  plane  made  of  gold  or  silver  may  be  fastened 
to  the  lower  teeth,  sloping  upwards  towards  the  palate,  which,  when 
the  jaws  are  brought  together,  forces  the  lower  one  backwards,  and 
the  upper  one  in  the  opposite  direction. 

Distortion  of  the  Lips  from  Burns. — The  surgeon  can  accom- 
plish a good  deal  in  preventing  deformity  of  the  lips,  following  burns, 
by  placing  those  organs  in  favorable  position  during  the  contraction 
of  the  cicatricial  tissue  filling  up  the  gaps  left  by  the  separation  of  the 
: sloughs.  The  contraction,  when  unopposed,  pulls  the  lips  downwards, 
everts  them,  thus  exposing  the  gums  and  teeth  to  view,  and  permitting 
the  saliva  to  flow  unobstructed  from  the  mouth. 

Treatment. — In  carrying  out  the  mechanical  treatment,  the  indica- 
tion is  to  make  pressure  upon  the  lips  against  the  teeth  and  to  raise 
the  chin.  This  may  be  done  by  the  following  appliance  (Fig.  205) : 
A metallic  stem  projects  from  the  apex 
of  a vertebral  lever  provided  with 
pelvic  straps  and  axillary  supports ; the 
stem  is  jointed  so  as  to  move  antero-pos- 
teriorly,  and  bears  at  its  top  two  curved 
arms  fitted  with  a movable  pad  at  their 
extremities,  which  is  intended  to  make 
pressure  upon  the  lips,  while  the  counter 
pressure  is  effected  by  a concave,  pad- 
ded disk,  moved  by  a screw  working 
through  the  stem  above  the  point  of 
attachment  of  the  arms,  acting  against 
the  occiput. 

Deformity  of  the  Chin  and  Neck 
from  Burns.  — Deformity  resulting 
from  burns  of  the  chin  and  neck  is 
often  considerable,  the  contracting 
inodular  tissue  dragging  down  the 
ohin  and  lips  to  the  chest,  destroying 
the  symmetry  and  impeding  the  per- 
formance of  the  functions  of  the  parts  so  as  to  place  the  patient  in  the 
nost  lamentable  plight. 

The  most  promising  time  for  the  mechanical  treatment  of  such  cases 
■s  during  cicatrization,  when  the  parts  can  be  easily  placed  and  held 
n any  desirable  position ; though  some  alleviation  of  the  deformity 
nay  be  brought  about  at  later  periods,  or  when  the  newly-formed 
issues  have  already  contracted. 


Fig.  205. 


292  APPARATUS  FOR  REMEDYING  LOSS  OF  SYMMETRY 


Fig.  206. 


The  most  complete  control  can  be  obtained  over  the  head  by  the 
use  of  an  appliance  (Fig.  206)  composed  of  a vertebral  lever,  axillary 
supports,  and  pelvic  straps,  to  which  is  added  a cervical  stem  with 

two  articulations,  to  obtain  motion,  an- 
tero-posteriorly  and  laterally.  From  the 
apex  of  this  stem  two  arms  project,  mov- 
ing vertically,  by  means  of  a joint,  and 
capable  of  being  opened  or  shut  by  simply 
turning  a screw.  The  ends  of  the  arms 
are  furnished  each  with  a short  stem, 
padded  at  both  of  its  extremities,  and  at 
right  angles  with  it.  These  pads  are 
intended  to  rest  upon  the  temples  and 
upper  jaw,  and  to  hold  the  head  firmly 
in  their  grasp. 

Another  form  of  instrument  may  be 
employed  when  the  chin  is  mainly  in- 
volved in  the  distortion.  It  consists  of 
a cervical  stem,  fixed  to  a vertebral 
lever,  as  in  the  previous  instrument, 
and  having  lateral  and  antero-posterior 
motion.  To  its  apex  are  affixed  curved, 
broad  arms,  grasping  the  occiput  as  far 
forward  as  the  temples ; the  point  of  one 
arm  supports  a vertical  lever  terminating 
in  a chin  rest.  With  this  instrument  it 
can  readily  be  understood  how  both  the  head  and  chin  may  be  placed 
in  any  desired  position. 

Posterior  Curvature  of  the  Neck. — This  deformity  consists  in 
the  formation  of  a posterior  curve  in  the  lower  cervical  and  upper 
dorsal  vertebrae ; sometimes  the  curve  involves  all  the  vertebrae  to  the 
last  lumbar,  constituting  what  has  been  called  posterior  curvature  of 
the  spine.  Persons  affected  in  the  former  manner  present  an  appear- 
ance generally  designated  as  round  shoulder,  or  stoop. 

Posterior  curvature  of  the  neck  occurs  in  young  persons  between 
10  and  16  years  of  age,  and  in  both  sexes.  Its  subjects  are  weakly, 
with  health  more  or  less  impaired,  soft  flabby  muscles,  and  growing 
rapidly.  This  condition  of  the  system  will  be  found  to  form  the 
groundwork  of  the  deformity,  while  its  exciting  causes  are  those 
employments  requiring  a person  to  stoop  constantly,  leaning  over 
desks,  &c. 

The  patient  at  first  can  readily  correct  the  mal-posture  of  the  neck 
when  directed  so  to  do,  but  by  degrees,  if  the  case  is  neglected,  the 
curve  becomes  permanent  in  consequence  of  the  anterior  edges  of  the 
intervertebral  cartilages  becoming  somewhat  atrophied  from  pressure, 
and  the  muscles  adapting  themselves  to  the  altered  position. 

This  curve  of  the  vertebrae  necessarily  causes  the  ribs  to  become 
more  prominent,  posteriorly  raising  the  scapulae,  and  in  this  manner 
giving  the  shoulders  the  rounded  outline  observed  in  these  cases ; at 
the  same  time  the  head  and  neck  sink  between  the  shoulders. 


Apparatus  for  preventing  deformity  after 
burns. 


OF  THE  HEAD  AND  NECK. 


293 


It  is  very  important  to  make  a careful  diagnosis  of  . this  deformity 
from  curvature  produced  by  caries  of  the  bodies  of  the  vertebras — 
angular  curvature,  as  it  is  called.  The  main  distinguishing  points  are, 
that  in  it,  the  obliteration  of  the  curve  occurs  when  the  patient  is 
placed  in  the  horizontal  position  upon  his  face,  and  the  spinous  pro- 
cesses form  an  uninterrupted  line,  features  never  observed  in  angular 
curvature. 

Treatment. — As  the  deformity  is  often  associated  with  the  strumous 
diathesis,  the  treatment  will  be  directed  to  the  removal  of  this  consti- 
tutional vice,  and  the  debilitated  condition  of  the  system.  From  what 
has  been  said  concerning  its  pathology,  the  mechanism  required  to 
meet  the  indications  of  the  case  is  readily  conceived.  A vertebral 
stem,  with  its  upper  extremity  expanded  and  well  padded  to  fit  the 
shoulders,  fastened  to  the  body  by  shoulder-straps  and  a pelvic  band. 
From  the  upper  part  of  the  dorsal  plate  a cervical  stem  projects,  bear- 
ing at  its  upper  end  two  curved  levers,  with  broad  and  padded  extre- 
mities to  support  the  chin ; these  move,  by  means  of  a ratchet  screw, 
vertically  and  laterally.  When  this  instrument  is  applied  the  shoulders 
are  drawn  back,  and  the  spine  and  head  supported  efficiently. 

Angular  Cervical  Curvature. — A disease  of  a much  more 
serious  character  than  the  one  just  now  considered  is  angular  curva- 
ture of  the  spine.  It  consists  most  often  in  a dyscrasic  condition  of 
the  solids  and  fluids  of  the  body  with  a deposition  of  the  matter  of 
scrofulosis  or  tuberculosis  into  the  bony  tissue  of  the  bodies  of  the 
vertebrae  with  subsequent  ulceration  or  caries  of  these  parts.  The 
most  frequent  seat  of  the  disease  is  in  the  dorsal  region,  and  eminently 
in  the  2d,  3d,  and  4th  pieces,  next  in  frequency  in  the  lumbar  region, 
and  lastly  in  the  cervical  vertebrae.  It  is  found  to  occur  in  all  classes, 
though  more  frequently  in  the  ill-fed,  badly  lodged  denizens  of  alleys 
and  lanes,  and  at  all  ages,  yet  more  especially  between  3 and  10  years, 
and  in  both  sexes. 

When  the  disease  occurs  in  the  cervical  region,  it  is  accompanied 
ivith  an  angular  projection  of  spinous  processes  of  one  or  more  ver- 
tebrae, which  distinguishes  it  from  posterior  cervical  curvature. 

Treatment. — In  these  cases,  besides  the  constitutional  and  local  treat- 
ment necessary,  it  is  indispensable  to  support  the  head  and  neck  by  a 
suitable  apparatus,  lest  in  some  unguarded  movement,  the  diseased 
vertebrae  cave  in  and  crush  the  spinal  cord. 

Mr.  Bishop,  of  London,  has  recommended  a contrivance  (Fig.  207) 
.vhich  will  answer  every  purpose.  It  is  simply  a broad  metallic  plate, 
itted  to  the  spine,  and  well  padded,  having  two  arms  affixed  to  its 
ipper  end,  in  which  the  occiput  is  intended  to  repose.  The  two  pieces 
ire  connected  by  a joint  which  permits  the  head  to  move  in  every  direc- 
ion,  except  laterally,  and  in  forced  extension.  The  instrument  is 
astened  to  the  person  by  shoulder-straps,  thoracic  and  pelvic  bands, 
n this  manner  the  cervical  vertebras  are  securely  held,  and  all  motion 
>f  the  head  in  perilous  directions  checked. 

To  answer  the  same  purpose,  a gutta-percha  shield  (Fig.  208), 
Qoulded  to  the  back  and  posterior  part  of  the  neck,  with  an  occipital 


294  APPARATUS  FOR  REMEDYING  LOSS  OF  SYMMETRY 


rest,  may  be  prepared  and  attached  to  the  body  by  a broad  thoracic 
band  and  shoulder-straps. 

These  two  forms  of  appliances  are  well  adapted  to  children,  who 
may  be  moved  about  securely,  without  fear  of  any  sudden  pressure 
upon  the  cord. 


Fig.  207. 


Fig.  208. 


For  the  purpose  of  permitting  ; 
of  fresh  air,  without  increasing 

Fig.  209. 


Bigg’s  apparatus  for  securing  immovability  of 
the  head,  in  caries  of  the  cervical  vertebra?. 


patient  to  stir  about  for  the  benefit 
the  spine  mischief,  Mr.  Bigg  has 
designed  an  instrument  (Fig.  209), 
composed  of  a vertebral  lever  and 
axillary  rest,  with  a stem  projecting 
from  its  upper  end,  bearing  two 
padded  arm-like  processes,  intended 
to  grasp  the  head,  from  the  occiput 
to  the  temporal  regions,  and  hold 
it  firmly ; the  arms  can  be  elevated 
or  depressed,  and  the  space  between 
them  increased  or  diminished. 

Torticollis,  or  Wry-Xeck. 
— This  deformity  consists  in  the 
permanent  contraction  of  the  cer- 
vical muscles,  principally  the  ster- 
no-cleido-mastoid,  which  draw  the 
occiput  towards  the  shoulder  of  the 
shortened  muscle,  while  the  face  is 
turned  in  a corresponding  degree 
in  an  opposite  direction.  The  causes 
are,  anything  that  destroys  the  bal- 
ance of  the  muscular  force  upon 
the  two  sides  of  the  neck,  such  as 
the  stronger  contraction  of  one  of 
the  sterno-cleido-mastoid  muscles, 


OF  THE  HEAD  AND  NECK. 


295 


while  the  other  retains  its  normal  activity ; or  one  muscle  may  become 
paralyzed,  thus  destroying  the  natural  muscular  antagonism.  Rheu- 
matic or  other  inflammation  of  the  parts  will  produce  the  same  result. 

1 The  disease  is  rarely  congenital,  and  is  observed  most  frequently 
between  the  third  and  tenth  year  of  age. 

Treatment. — Simple  mechanical  treatment  will  succeed,  in  mild 
cases,  in  restoring  the  head  to  its  natural  position;  the  severer  ones 
will  require  the  preliminary  use  of  the  knife  to  divide  the  tendon  of 
the  contracted  muscle  before  the  mechanical  means  are  resorted  to. 

An  apparatus  sometimes  employed  is  that  of  Prof.  Jorg(Fig.  210), 
composed  of  a leather  corset,  and  a fillet  to  encircle  the  head;  these 
are  connected  by  a small  steel  bar,  moved  by  a ratchet  arrangement 
under  the  control  of  a key. 


Bonnet  invented  a much  more  ingenious  and  efficient  apparatus, 
(Fig.  211)  that  does  not  embrace  the  chest  and  impede  respiration.  It 
consists  of  a plate  of  gutta-percha,  modelled  to  the  back  and  shoulders, 
to  which  it  is  fastened  by  straps  passing  beneath  the  axillas  and 
around  the  waist.  From  the  back  part  of  this  shield  a metallic  rod 
; ascends,  curving  over  the  head,  and  capable  of  motion  antero-poste- 
riorly  and  laterally,  by  means  of  a ratchet-wheel.  Through  the  top  of 
the  rod  a screw  works,  supporting  two  padded  arms,  to  grasp  the  sides 
of  the  head,  and  when  in  place  they  are  secured  by  a strap  passing 
beneath  the  chin. 

By  this  arrangement  the  head  may  be  held  in  any  desired  position. 


296  APPAEATUS  FOE  BE  ME  D YIN  G LOSS  OF  SYMMETEY 


Fisc-  212. 


An  efficient  contrivance  was  invented  by  Mr.  Bigg,  of  London 
(Fig.  212),  who  describes  it  as  “consisting  of  a padded  pelvic  band,  to 
which  is  attached  a vertebral  stem  with  hori- 
zontal arm-pieces.  At  the  upper  extremity  of 
the  vertebral  stem  a neck-lever  is  fixed,  to  be 
attached  or  detached  at  will.  This  lever  is 
formed  in  a peculiar  fashion.  It  passes  around 
the  head,  and  rests,  by  its  outer  extremity, 
against  the  temporal  bone,  on  the  side  towards 
which  the  head  is  deflected.  On  the  opposite 
side  of  the  head  a horizontal  lever  is  fixed,  also 
springing  from  the  vertebral  stem,  and  resting 
against  the  lower  jaw.  The  temporal  lever  has  a 
vertical  axis,  moved  by  a ratchet-joint,  upon  turn- 
ing which  the  head  is  gently  pressed  in  a hori- 
zontal direction.  The  lower-jaw  lever  also  acts 
horizontally,  but  in  a different  plane.”  He  re- 
marks: “ That  by  the  conjoint  action  of  these 
two  levers  the  contracted  sterno-mastoideus 
muscle  is  extended,  the  head  restored  to  an 
erect  position,  and  the  chin  brought  into  the 
mesial  line  of  the  body.  From  the  position  of 
the  lever,  displacement  of  the  head,  when  the 
instrument  is  properly  applied,  is  impossible, 
and  by  a little  modification  of  the  dress  and 
arrangement  of  the  hair  the  mechanism  may 
be  almost  entirely  concealed.” 

A greater  range  of  motion  of  the  arms,  in 
which  the  head  is  grasped,  is  secured  by  the  apparatus  seen  in  Fig. 
213,  which,  besides  being  enabled  to  change  the  position  by  the  connec- 


Bigg’s  apparatus  for  tor- 
ticollis. 


Fig.  213. 


Apparatus  for  torticollis. 


Fig.  214. 


Same  applied. 


Fig.  215. 


tion  of  their  rods  with  the  vertebral  stem,  also  possess  centres  of  motion 
at  their  apices;  the  extent  of  motion  being  regulated  by  thumb-screws. 
The  mode  of  applying  the  apparatus  is  shown  in  Fig.  214. 

Of  all  the  forms  of  apparatus  for  the  treatment  of  torticollis,  the 
one  seen  in  Fig.  215  is  preferred  by  me.  It  consists  of  a pelvic  strap 


OF  THE  TRUSTS. 


297 


and  a vertebral  stem,  reaching  to  the  occiput,  and  bearing  padded  me- 
tallic arms  to  grasp  the  head  firmly ; the  arms  are  perforated  upon 
both  sides  by  oval  openings,  which  leave  the  ears  uncovered  ; to  enable 
the  arms  to  hold  the  head  more  securely,  a chin  and  a frontal  strap 
are  fastened  to  them. 

To  give  stability  to  the  vertebral  lever  two  axillary  supports  and 
shoulder-straps  are  attached  to  it. 

The  vertebral  lever  has,  at  its  upper  part,  two  centres  of  motion, 
one  antero-posterior,  and  the  other  lateral,  controlled  by  a key,  which 
enable  the  surgeon  to  manage  the  movements  of  the  head  in  the  most 
perfect  manner. 

Where  it  is  practicable,  it  is  always  desirable,  in  using  wry-neck 
apparatus,  that  they  take  their  point  d'appui  upon  the  hips,  which 
confers  upon  them  greater  stability  and  power  of  holding  the  head 
firmly.  If,  from  any  cause,  this  arrangement  cannot  be  pursued,  Bon- 
net has  suggested  an  apparatus  to  meet  the  emergency.  It  is  con- 
structed of  a broad  metallic  plate,  fitting  the  shoulders,  and  connected 
to  them  by  straps  passing  under  the  axillas  and  across  the  breast. 
Upon  each  side  of  the  collar  a vertical  bar  is  soldered,  supporting 
at  its  apex  a horizontal  screw  armed  with  a concave  padded  plate. 
One  plate  is  intended  to  press  against  the  lower  jaw  upon  one  side, 
and  the  other  plate  upon  the  cheek-bone  on  the  opposite  side. 

With  the  same  view  Mr.  Bigg  suggests  the  use  of  a better  instru- 
ment, consisting  of  a curved  piece  of  steel  resting  upon  the  shoulder 
towards  which  the  head  is  drawn,  and  retained  in  place  by  padded 
straps  which  pass  under  the  shoulders.  From  the  plate  spring  two 
levers  with  padded  extremities.  These  levers  are  so  arranged  that 
one  rests  on  the  parietal  region  of  the  contracted  side,  and  the  other 
on  the  mastoid  process  of  the  opposite  side,  their  action  being  governed 
and  directed  by  ratchet  screws. 

SECTION  II. 

APPARATUS  FOR  REMEDYING  LOSS  OF  SYMMETRY  OF  THE  TRUNK. 

Lateral  Curvature  of  Spine. — The  deformity  now  under  con- 
sideration is  unconnected  with  ulcerative  diseases  of  the  vertebras  or 
caries,  as  is  the  case  in  angular  curvature,  except  in  extremely  rare 
cases.  The  disease  in  the  great  majority  of  instances  is  observed  among 
girls  in  the  upper  classes  of  society,  between  the  ages  of  twelve  and 
eighteen  years. 

Symptoms. — The  disease  often  begins  insidiously,  making  decided 
progress  before  the  parents  of  the  patient  are  fully  aware  of  the  seri- 
ousness of  the  condition  of  their  daughter ; perhaps,  on  inquiry,  the 
.physician  will  find  some  time  to  have  elapsed  since  the  first  deviation 
inform  was  observed,  appearing  to  be  an  “ outgrowing ” of  the  shoulder 
and  corresponding  breast.  The  patient’s  general  health  will  sometimes 
remain  undisturbed  antecedent  to  the  spinal  deflection,  though  most 
often  it  will  be  found  to  have  been  more  or  less  deranged.  The  appe- 
tite fails,  the  bowels  become  constipated,  and  the  nutrition  defective, 


298  APPARATUS  FOR  REMEDYING  LOSS  OF  SYMMETRY 

so  that  the  patient  loses  flesh,  is  easily  fatigued,  and  constantly  seeks 
rest  in  a horizontal  position. 

In  some  instances,  along  with  the  feeling  of  great  weariness,  there 
will  be  more  or  less  pain  experienced  in  the  back;  sometimes  the  pain 
is  continuous,  and  referred  to  the  left  side  below  the  ribs. 

In  cases  that  have  made  some  progress,  the  spinal  column  will  he 
seen  to  have  curved  in  the  dorsal  region  to  the  right,  and  in  the  lum- 
bar to  the  left;  this  is  by  far  the  most  common  condition,  though  the 
reverse  may  sometimes  be  observed  in  boys,  and  it  then  always  depends 
upon  the  inordinate  exercise  of  the  muscles  of  one  side  or  upon  the  main- 
tenance of  the  body  in  awkward  positions.  The  dorsal  curve  carries 
with  it  the  ribs,  and  pushes  those  upon  the  right  side  backwards, 
forming  a protuberance  beneath  the  scapula,  which  then  presents  an 
unnatural  prominence  while  the  corresponding  shoulder  will  be 
found  elevated  and  projecting.  The  ribs  connected  with  the  concavity 
of  the  curve  are  flattened  and  the  corresponding  shoulder  depressed. 
The  formation  of  the  lumbar  curve  causes  a disproportionate  promi- 
nence of  the  left  hip,  while  the  right  one  sinks  in  a corresponding 
degree.  These  changes  are  well  shown  in  Fig.  216. 


If  a third  curve,  formed  by  the  upper  dorsal  and  lower  cervical, 
exists,  as  is  sometimes  seen  (Fig.  217),  the  external  characteristics  of 
the  disease  now  mentioned  will  be  modified  to  some  extent.  The 
side  of  the  chest  upon  the  convexity  of  the  dorsal  curve  becomes 
flattened,  the  corresponding  side  of  the  neck  falls  in,  while  the  oppo- 
site side  of  the  neck  and  chest  appears  much  fuller,  and  is  accompanied 
with  an  elevation  of  the  shoulder ; yet,  though  its  scapula  is  higher, 
it  does  not  project  so  much  as  the  scapula  upon  the  dorsal  curvature. 


Fig.  216. 


Fig.  217. 


External  appearances  of  lateral  curvature. 


OF  THE  TRUNK. 


299 


In  aggravated  cases  besides  these  mesial  curvatures  there  is  added 
another — helical  curvature — formed  by  the  bodies  of  the  vertebrae 
rotating  upon  their  own  axes  in  the  direction  of  the  concavity  of  the 
curvature. 

The  shape  and  capacity  of  the  chest  are  altered  in  consequence  of  the 
ribs  becoming  elongated,  flattened,  and  twisted,  thrusting  the  sternum 
and  costal  cartilages  forwards,  while  they  are  unnaturally  approxi- 
mated to  the  pelvis.  The  spine  is  decreased  in  height,  the  muscles  and 
ligaments  upon  its  convexities  stretched,  and  if  the  deformity  results 
from  excessive  use  of  the  limb  upon  one  side  they  will  be  found  more 
vigorous  than  their  congeners,  while  those  located  in  the  concavities 
of  curvature  are  preternaturallv  contracted,  atrophied,  and  rigid. 
These  changes  in  the  bones  of  the  spine  and  the  ribs  are  seen  in  the 
annexed  sketches. 


Fig.  218. 


Fig.  219. 


Appearances  of  the  bones  in  lateral  curvature  of  spine ; front  and  back  views. 


The  causes  of  lateral  curvature  are  numerous,  some  of  the  principal 
are  : Unequal  muscular  action,  by  which  one  set  of  muscles  acts  more 
vigorously  upon  the  spine  than  those  that  counterbalance  them,  thus 
drawing  it  to  one  side ; this  is  seen  in  blacksmiths,  dragoons,  and 
those  persons  who  use  one  arm  more  than  the  other.  The  same  result 
will  follow  if  the  equilibrium  is  destroyed  by  the  muscles  upon  one 
side  of  the  spine  becoming  debilitated  or  paralyzed  from  any  cause, 
the  stronger  muscles  will  drag  the  spine  towards  their  side.  Any- 
thing that  mars  the  uniform  growth  and  development  of  the  muscles 
will  be  likely  to  cause  lateral  curvature;  we  see  this  exemplified  in 


300  APPARATUS  FOR  REMEDYING  LOSS  OF  SYMMETRY 

females  who  indulge  in  the  pernicious  habit  of  tight  lacing,  “the 
common  effect  of  which  practice  is  obstruction  in  the  lungs,  from 
their  not  having  sufficient  room  to  play,  which,  besides  tainting  the 
breath,  cuts  off  numbers  of  young  women  in  the  very  bloom  of  life. 
But  nature  has  shown  her  resentment  of  this  practice,  by  rendering 
above  half  the  women  of  fashion  deformed  in  some  degree  or  other.” 

The  fatigue  of  the  spinal  muscles  produced  bv  sitting  with  the  back 
unsupported,  for  lengthy  periods ; habitually  assuming  awkward 
positions  in  standing,  sitting,  or  lying  will  also  induce  it.  Obliquity  of 
the  pelvis  from  inequality  of  the  length  of  the  lower  extremities,  the 
wooden  pin,  and  other  badly  constructed  artificial  limbs  are  fruitful 
sources  of  spinal  distortion. 

Lastly,  rickets  will  often  be  found  to  predispose  to  this  deformity. 

Treatment. — The  successful  treatment  of  lateral  curvature  requires 
on  the  part  of  the  patient  determination  of  will  and  a faithful  ad- 
herence to  the  directions  of  the  surgeon,  inasmuch  as  the  benefit  to 
be  obtained  is  not  a question  of  days,  but  one  of  months.  In  the 
early  stage  of  the  disease,  it  may  generally  be  overcome  and  a favor- 
able issue  brought  about;  later,  when  the  deformity  has  become  firmly 
established,  the  most  that  can  be  done  is  to  ameliorate  the  patient’s 
condition.  Under  the  latter  circumstances,  the  person  should  be 
promptly  informed  that  two  years  of  patient  treatment,  at  least,  will 
be  required  to  obtain  any  decided  and  permanent  improvement. 

The  first  object  should  be  to  investigate  carefully  the  cause  of  the 
deformity ; perhaps  the  removal  of  this  will  arrest  the  progress  of 
the  spinal  deflexion  at  once : for  instance,  inequality  of  length  of  the 
legs,  from  fractures,  hip  or  knee  disease,  &c.,  must  be  corrected  by  the 
use  of  proper  mechanical  appliances,  and  the  spine,  by  its  own  elas- 
ticity, will  restore,  in  a short  time,  symmetry  to  the  form. 

Constitutional  treatment  is  indispensable.  Efforts  should  be  made 
to  establish  the  general  health ; to  correct,  as  far  as  possible,  the 
derangements  of  the  stomach,  bowels,  and  uterus  so  often  observed 
in  these  cases;  and  to  surround  the  patient  by  favorable  hygienic 
conditions. 

As  to  the  mechanical  treatment,  surgeons  have  differed  in  opinion. 
Mr.  Skey  directs  that  the  patient  should  be  placed  in  the  horizontal 
position  to  remove  “the  cause  of  the  entire  evil,  viz.,  the  superincum- 
bent weight.”  He  regards  the  horizontal  position  as  quite  compatible 
with  health,  with  education,  and  with  the  enjoyment  of  life.  His  plan 
is  to  select  a narrow  bedstead  about  three  feet  in  width,  running  on 
large  wooden  castors,  by  means  of  which  it  may  be  wheeled  about  in 
any  direction.  Upon  this  is  placed  a well-made  wool  mattress.  When 
the  patient  is  stretched  upon  this,  he  endeavors  to  unfold  the  spinal 
curves  by  making  extension  from  the  two  extremities  of  the  spinal 
column;  that  above  by  a belt  applied  around  the  chin  and  occiput, 
attached  to  a cord  passing  over  a pulley  let  into  the  head-board  of  the 
bed,  and  supporting  a weight  of  from  ten  to  twenty  pounds.  That 
below  is  attached  by  a broad  belt  around  the  pelvis,  and  including 
the  crista  of  each  ilium.  To  the  sides  of  this  belt  are  two  straps,  that 
unite  below,  and  to  them  may  be  attached  a weight  of  from  twenty  to 


OF  THE  TRUNK. 


301 


thirty  pounds.  This  extension  may  be  worn  sixteen  hours  out  of  the 
twenty-four  of  each  day  and  night.  To  restore  the  projecting  ribs  to 
their  natural  form  and  relation,  he  employs  a large  pad  covered  with 
soft  leather,  arched  to  fit  the  projecting  curve,  and  borne  by  a screw 
passing  through  an  upright  fastened  to  the  bedstead ; counter-pressure 
is  established  by  two  similar  but  smaller  pads  acting  upon  the  oppo- 
site hip  and  back  of  the  neck.  The  large  pad  should  be  made  so  as 
to  press,  not  in  the  transverse  or  horizontal  direction,  but  in  that 
obliquely  forwards ; the  smaller  pads  may  press  horizontally.  This 
lateral  pressure  should  be  maintained  as  firmly  as  the  patient  can  bear, 
for  much  of  the  success  of  the  treatment  depends  on  its  efficacy  and 
permanence. 

To  enlarge  the  capacity  of  the  diminished  half  of  the  chest,  he 
endeavors,  by  compressing  the  abdomen  with  a thick  and  soft  pad  of 
lint  or  cotton-wool,  or  a pad  containing  bran  or  horse-hair,  and  a 
broad  bandage,  to  control  the  action  of  the  diaphragm,  and  throw  the 
duty  of  inspiration  on  the  intercostal  muscles,  which  are  in  a reduced 
and  weakened  condition.  Mr.  Skey  remarks,  in  relation  to  this  prin- 
ciple of  treatment,  that  “ it  should  be  persisted  in  till  observation  of 
the  back,  to  be  occasionally  made,  obtain  conclusive  evidence  of  posi- 
tive improvement.  Nor,  indeed,  should  it  even  then  be  desisted  from, 
but  rather  modified  as  we  approach,  at  the  expiration  of  from  eighteen 
months  to  two  years,  or  possibly  more,  the  period  for  entering  on  the 
second  stage  of  the  treatment — gymnastic  exercises.” 

Similar  to  this  couch,  but  gotten  up  with  more  elegance  of  me- 
chanism, is  a contrivance  represented  in  Fig.  220,  and  employed  by 


Fig.  220. 


some  of  the  German  surgeons.  It  consists  of  three  sections,  the  upper 
one  corresponding  to  the  cervical,  the  middle  to  the  dorsal,  and  the 
third  section  to  the  lumbar  curvature.  To  the  upper  end  of  the  couch, 
a padded  receptacle  for  the  head  is  fixed,  carrying  a chin  pad  and 
strap.  A.  padded  band  for  the  pelvis  is  connected  by  two  lateral 
straps  to  a strong  metallic  spring  secured  to  the  foot  of  the  couch. 
These  are  the  mechanical  provisions  for  permanent  extension.  To 
compress  the  dorsal  curvatures,  a broad  pad  is  attached  to  the  right 
edge  of  the  plane ; and  two  smaller  ones  to  the  left  edge,  to  make 
counter-pressure  upon  the  cervical  and  lumbar  curves.  By  means  of 


302  APPAEATUS  POE  EEMEDYING  LOSS  OF  SYMMETEY 

a screw,  the  upper  and  middle  sections  are  separated  upon  their  left 
edge  only,  while  a similar  motion  is  impressed  upon  the  middle  and 
lower  sections  at  the  right  edge. 

The  mechanical  principle  of  the  couch  is  evident : the  arcs  of  the 
spine  are  extended  from  their*  extremities,  while  the  pads  exercise 
pressure  upon  their  apices ; the  hinge  movements  of  the  sections  act 
upon  the  column  in  opposite  directions  to  its  inflections. 

An  ingenious  couch  (Fig.  121),  invented  by  Mr.  Bigg,  does  not  re- 
strain the  movements  of  the  patient  to  the  same  extent  as  the  two 
described  above,  and  will  be  found  useful  in  cases  of  moderate  curva- 
ture, or  in  nervous  persons  as  preliminary  to  the  employment  of  more 
efficient  couches  requiring  greater  immobility  of  the  body. 


Fig.  221. 


He  describes  it  in  the  following  manner : “ The  couch  consists  of  a 
well-padded  surface,  having  a rest  for  the  head,  which  can  be  moved 
obliquely  upwards  by  means  of  an  elastic  cord  fixed  to  the  upper  rail 
of  the  plane.” 

“At  the  lower  edge  of  the  plane  another  rail  is  arranged  for  the 
attachment  of  two  elastic  bands  belonging  to  a padded  belt,  which  is 
fastened  round  the  hips.  Another  rail  is  arranged  at  the  side  corres- 
ponding with  the  dorsal  curve,  and  a fourth  rail  is  fixed  at  the  lateral 
edge  of  the  plane  answering  to  the  lumbar  curve.  To  both  these  rails 
soft  webbing  bands  are  fastened  by  elastic  cords,  and  these  webbing 
bands  pass  in  antagonistic  directions  over  the  arcs  of  dorsal  and  lum- 
bar deflections.” 

The  apparatus  contrived  by  Valerius,  a mechanician  of  Paris,  called 
the  “corset-lit,”  is  a very  ingenious  contrivance,  and  answers  all  the 
indications  of  treatment  of  lateral  curvature  as  fully  as  any  of  the 
couches  hitherto  brought  to  the  notice  of  the  medical  profession. 

The  mechanism  consists  of  a padded  model  or  mould  of  the  poste- 
rior and  lateral  planes  of  the  body  divided  into  three  sections,  the  first 
to  embrace  the  back  and  chest,  the  second  the  loins,  and  the  third  sec- 


OF  THE  TRUNK. 


303 


tion  to  inclose  the  hips ; these  are  susceptible  of  vertical  and  lateral 
movements  by  means  of  screw  power,  and  may  be  placed  at  any  angle 
that  may  be  deemed,  by  the  surgeon,  the  most  expedient  for  the  case 
.under  treatment.  The  head  is  secured  in  a padded  support  resembling 
somewhat  the  back  part  of  a casque,  and  capable  of  being  varied  at 
any  angle,  while  the  body  is  rendered  immovable  by  shoulder  and 
pelvic  straps.  The  frame  itself  is  supported  upon  a board  by  means 
of  straps. 

Some  persons  have  deemed  it  necessary  to  make  extension  only  in 
the  recumbent  posture  without  lateral  compression.  This  was  the 
practice  of  Hippocrates,  who  established  as  points  of  extension  the 
shoulders  and  hips  of  the  patient.  In  France  most  of  the  couches  are 
arranged  with  the  upper  extending  cords  acting  upon  the  head.  Of 
this  sort  is  the  one  seen  in  Fig.  222,  and  employed  by  Dr.  Maisonabe. 


Fig.  222. 


Mr.  Tamplin,  Erichsen,  and  others  believe  that,  except  in  altogether 
exceptional  cases,  continuous  treatment  in  the  recumbent  posture  is 
pernicious,  and,  therefore,  if  patients  can  get  around  with  any  degree 
of  comfort,  it  is  the  most  judicious  plan  to  employ  some  form  of  spinal 
supporter,  permitting  them  to  go  out  in  the  open  air,  and  have  recourse 
to  some  kind  of  gymnastic  exercise  in  order  to  strengthen  the  serrati, 
rhomboidei,  and  the  erector  muscles  of  the  spine. 

These  instruments  are  of  two  classes.  1st.  Those  that  remove  the 
weight  of  the  head  and  upper  extremities  from  the  spine,  and  make 
lateral  pressure  upon  it  in  opposite  directions.  2d.  Those  that  simply 
remove  the  weight  without  making  the  pressure. 

From  what  we  have  already  stated  concerning  the  mechanism  of 
lateral  curvature— that  usually  we  find  two  curves  formed,  one  in  the 
dorsal  region  towards  the  right  side,  and  the  other  or  compensative 
Icurve  in  the  loins  looking  to  the  left  side,  the  vertebrae,  as  the  disease 
advances,  rotating  always  in  the  direction  of  the  concavity  of  curvature 
, — itcan  readily  be  gathered  that  those  instruments  must  be  most  efficient 
that  oppose  these  displacements,  by  the  exercise  of  an  antagonistic  force, 
with  appropriate  levers  and  pads.  Those  belonging  to  the  first  class 
,are  most  esteemed  by  surgeons  in  the  treatment  of  lateral  curvature; 
■some  of  them  exercise  lateral  force  in  opposite  directions  simply,  while 
others  have  a rotatory  action.  In  their  construction  provision  is  also 


304  APPARATUS  FOR  REMEDYING  LOSS  OF  SYMMETRY 


sometimes  made  to  elevate  the  depressed  shoulder,  or  to  depress  the 
elevated  one. 

The  simplest  form  of  a spine  supporter,  exercising  lateral  pressure, 
is  a simple  corset  which  transfers  some  of  the  weight  of  the  upper  ex- 
tremities to  the  pelvis,  but  has  at  the  same  time  the  insuperable  ob- 
jection of  compressing  the  chest,  and  impeding  the  development  of 
muscular  energy.  Therefore  it  should  be  banished  from  use,  particu- 
larly as  there  are  other  apparatus  more  efficient  without  these  dis- 
advantages involved  in  their  construction. 

A modification  of  the  corset  is  seen  in  Fig.  223.  Two  lateral 
crutch-form  supports  and  a vertebral  lever  are  connected  with  the 
corset,  the  latter  bearing  at  its  apex  a broad  webbing  band  which 
crosses  over  the  dorsal  convexity,  then  passes  in  front  of  the  corset,  and 
is  finally  attached  by  means  of  a buckle  to  an  arm  projecting  from 
the  base  of  the  lever. 


Mr.  Tamplin  found  Tavernier’s  lever-belt  (Fig.  224)  an  excellent 
instrument  in  any  slight  case  of  curvature,  wrhich  it  promptly  cured. 
Mr.  Erichsen  says  that  by  this  contrivance  alone,  properly  and  care- 
fully adjusted  to  the  condition  of  the  deformity,  many  patients  may 
be  treated  without  the  necessity  of  any  confinement  whatever.  It 
consists,  as  seen  in  the  wood-cut  annexed,  of  a well-fitted  pelvic  belt, 
bearing  a vertebral  lever,  having  attached  to  its  apex  a triangular 
band  of  webbing,  which  is  intended  to  pass  over  and  compress  the 
dorsal  curvature,  and  to  fasten  by  its  apex  to  the  point  of  a short  stem 


Fig.  223. 


Fig.  224. 


Apparatus  for  lateral  curvature. 


Tavernier’s  apparatus  for  lateral  curvature. 


OF  THE  TKUNK. 


305 


attached  to  the  pelvic  belt.  To  prevent  the  apparatus  tilting  or  slipping 
up,  a thigh-strap  is  sometimes  attached,  encircling  the  left  hip. 

In  severe  cases  of  curvature,  Mr.  Tamplin  found  another  form  of 
supporter  preferable.  It  consists,  as  seen  in  the  sketch  (Fig.  225),  of  a 


Fig.  225. 


band  which  encircles  the  pelvis,  having  a vertebral  stem  attached 
behind,  at  the  upper  portion  of  which  is  a movable  pad,  so  made  that 
it  adapts  itself  to  the  projecting  ribs,  and  with  the  screw  the  pressure 
can  be  regulated  according  to  circumstances;  beneath  is  an  arm, 
Avhich  extends  to  the  opposite  side  of  the  band,  and  which  regulates 
the  position  of  the  vertebral  stem,  without  causing  the  instrument  to 
be  displaced  to  any  extent,  by  means  of  the  screw  presented  in  the 
diagram. 

The  apparatus  of  Mr.  Lonsdale  is  similar  to  that  of  Tavernier; 
there  is  added  a crutch  support,  which  sustains  the  depressed  shoulder 
and  obviates  the  tilting  of  the  pelvic  belt.  It  will  be  seen  that 
i these  forms  of  instruments  act  upon  the  dorsal  curve  only  of  the 
spine,  leaving  the  lumbar  curve  unsupported,  while  the  counter- 
pressure comes  upon  the  left  hip  through  the  pelvic  strap.  To  carry 
out  fully  the  mechanical  requirements  demanded  in  lateral  curvature, 
it  should  be  the  object  of  the  surgeon  to  bring  pressure  upon  the 
apices  of  the  arcs  of  curvature,  by  two  lateral  arms  projecting  from 
. 20 


806  APPARATUS  FOR  REMEDYING  LOSS  OF  SYMMETRY 


a vertebral  lever,  supported  by  a padded  pelvic  band,  to  expand  the 
curves ; and  in  those  cases  where  rotation  of  the  vertebrae  has  taken 
place,  to  bring  pressure  upon  the  ribs  by  two  opposite  parallel  forces. 


Fig.  226. 


Lonsdale’s  apparatus  for  lateral  curvature. 


Fig  227. 


An  instrument  partially  based  upon  this  principle  is  much  employed 
in  this  country.  It  consists  of  pelvic  straps,  to  which  a vertebral  stem 
is  attached,  bearing  at  its  sides  two  padded  elastic  plates  to  press  upon 
the  dorsal  and  lumbar  curves  in  opposite  directions ; and  at  its  top  two 
horizontal  arms  projecting  beneath  the  axillas,  movable  vertically  and 
obliquely,  by  which  the  depressed  shoulder  may  be  elevated. 

Mr.  Bigg,  of  London,  to  secure  these  advantages,  has  invented  the 
instrument  shown  in  the  annexed  woodcut  (Fig.  227),  which  has  for 
its  object  pressure  upon  the  curves  in  opposite  directions,  and  rota- 
tive action  upon  the  twisted  vertebra  and 
ribs.  He  thus  describes  it:  ‘‘It  consists  of 
a pelvic  band  sustaining  two  lateral  up- 
rights and  a vertebral  stem  which  carries  a 
shoulder-plate.  At  the  base  of  the  back 
lever,  where  it  joins  the  pelvic  band,  two 
centres  of  movement  are  placed,  one  (a) 
acting  anteriorly,  the  other  (b)  in  a lateral 
direction.  Thus,  on  moving  the  former, 
pressure  of  the  plate  forwards  against  the 
shoulder  is  caused,  and  on  moving  the  lat- 
ter, lateral  pressure  against  the  ribs.  The 
plate  itself  also  has  two  centres  of  move- 
ment ; one  (c)  corresponding  with  the  hori- 
, , , zontal  rotation  of  the  ribs  on  the  spine,  and 

apparatus  for  lateral  curva-  . , . . . , 1 1 

ture.  the  other  (d)  moving  the  plate  m a vertical 


OF  THE  TRUNK. 


307 


Fig.  228. 


direction  around  its  centre  of  attachment.  By  means  of  the  hori- 
zontal shoulder  movement  (c)  it  was  sought  to  act  upon  and  re-rotate 
the  ribs  in  an  anterior  direction.  A controlling  pressure  was  exer- 
cised upon  the  curvature  by  the  movement  (b)  at  the  base  of  the 
vertebral  lever.  The  shoulder  itself  was  attempted  to  be  depressed 
by  the  action  of  the  vertical  axis  (d)  in  the  shoulder-plate.”  As 
there  was  no  counter  pressure  to  the  force  exercised  by  the  plate  (d), 
little  rotative  action  could  have  been  expected,  and  it  was  to  remedy 
this  that  he  attached  to  the  instrument  subsequently,  when  the  defect 
was  observed,  a padded  plate,  to  rest  against  the  antero-lateral  surface 
of  the  thorax. 

A very  efficient  supporter  (Fig.  228),  in  cases  of  moderate  lateral 
curvature,  was  much  employed  by  Sir 
B.  Brodie,  and  invented  by  a London 
mechanician;  in  it  there  is  an  arrange- 
ment provided  for  depressing  the  elevated 
shoulder.  It  is  constructed  with  a pelvic 
band  and  hip-straps  supporting  two  late- 
ral crutch-like  arms  to  support  the  shoul- 
ders, and  a vertebral  stem  connected  with 
the  lateral  crutch  by  a metallic  rod  at  its 
apex.  Upon  the  right  shoulder  there  is 
a cap  connected  by  a band  to  the  pelvic 
belt,  with  a view  to  depress  the  former. 

Pressure  is  made  upon  the  dorsal  curve 
by  a broad  padded  lacing-belt  extending 
between  the  vertebral  lever  and  the  riarht 

o 

crutch.  The  lumbar  curve  is  acted  upon 
by  a pad  and  strap  crossing  the  left  hip 
obliquely. 


It  has  been  proposed,  and  the 
principle  has  been  carried  out 
in  a number  of  appliances  for 
rectifying  spinal  curvature,  to 
: substitute  the  pressure  of  elastic 
cords  for  that  of  metallic  plates 
moved  by  levers,  ratchet-cen- 
tres, and  screws.  This  plan 
is  adopted  in  the  contrivances 
of  Chelius,  Joerge,  and  Du- 
chenne.  A sketch  of  the  in- 
strument of  the  latter  is  seen  in 
the  drawing  (Fig.  229).  It  con- 
sists of  a broad  pelvic  belt  (c) 
supporting  a vertebral  lever  (d) 
movable  laterally  at  the  point 
where  the  two  parts  connect.  At 
the  apex  of  the  back  stem  a lever 
belt  (a)  is  attached  which  passes 
over  the  dorsal  curve  to  be 


Fig.  229. 


308  APPARATUS  FOR  REMEDYING  LOSS  OF  SYMMETRY 


fastened  in  front.  B j means  of  elastic  straps  (k)  extending  between  the 
vertebral  lever  and  pelvic  belt  the  former  is  drawn  over  towards  the 
side  of  tbe  convexity  of  lumbar  curvature,  and  the  lever-strap  thus 
pressed  firmly  against  the  dorsal  curve.  A crutch  support  passes  also 
from  the  pelvic  belt  beneath  the  axilla  of  the  lower  shoulder. 

A skilled  mechanician  of  this  city,  Mr.  Kolbe,  has  improved  the 
apparatus  of  Duchenne  somewhat  by  changing  the  attachment  of  the 
elastic  straps  from  the  pelvic  belt  to  the  lateral  crutch  (Fig.  230),  so 
that  they  act  to  a better  mechanical  advantage;  greater  firmness  is 
also  conferred  upon  it  by  the  introduction  into  the  pelvic  belt  of  two 
oval  metallic  supports  bent  to  fit  the  hip  at  each  side. 


Fig.  230. 


Fig.  231. 


Apparatus  for  lateral  curvature. 


The  second  class  of  spinal  supporters  act  by  simply  removing  the 
weight  of  the  head  and  upper  extremities  from  the  spine  and  trans- 
ferring it  to  the  hips.  One  of  the  simplest  and  oldest  of  these  forms 
is  seen  in  Fig.  231.  It  is  prepared  by  fitting  to  the  hips  a well-padded 
belt,  supporting  two  lateral  crutches  for  supporting  the  shoulders, 
connected  together  by  broad  thoracic  bands.  This  is  an  efficient  con- 
trivance, and  will,  perhaps,  serve  every  purpose  that  any  of  the  instru- 
ments of  this  class  are  capable  of. 

Bonnet  and  a good  many  of  the  French  surgeons  employ  padded 
shields  of  the  exact  contour  of  the  posterior  surface  of  the  body, 
fastening  them  by  means  of  thoracic  and  abdominal  straps.  They 
are  expensive,  rather  heavy,  and  more  fatiguing  to  patients  than  the 
previously  described  apparatus. 

In  rare  cases,  as  has  already  been  stated,  instead  of  the  two  or  three 
curves  usually  seen  in  this  deformity,  the  spine  presents  a single 
dorsal  curve  to  either  one  side  or  the  other.  The  shoulder  and  hip 
upon  the  side  corresponding  with  the  concavity  are  more  or  less 
approximated,  while  those  upon  the  opposite  side  are  separated  in  a 
corresponding  degree  and  more  prominent. 

The  mechanical  apparatus  required  in  single  lateral  curvature, 
when  of  moderate  severity,  may  be  constructed  upon  the  principle  of 
the  apparatus  already  described,  or  the  simple  appliance  sketched 
below  (Fig.  232)  will  answer  very  well. 


OF  THE  TRUNK. 


309 


Apparatus  for  single  curvature  of  the  spine.  Appearance  of  posterior  curvature. 

Posterior  Curvature  of  the  Spine. — We  have  already  con- 
sidered posterior  curvature  as  it  affects  the  cervical  vertebrfe,  and 
therefore  it  remains  for  us  to  describe  this  deformity  as  it  occurs  in 
the  dorsal  region.  When  the  back  is  viewed  from  behind  one  con- 
tinuous and  uniform  curve  will  be  seen  extending  from  the  lower 
cervical  to  the  last  lumbar,  as  shown  in  Fig.  233. 

This  condition  is  most  frequently  met  with  in  young  children,  and 
infants  under  twelve  months  of  age.  The  patients  presenting  the  de- 
formity will  be  found  suffering  more  or  less  from  general  debility  and 
; relaxation  of  the  muscles  and  ligaments,  so  that  the  weight  of  the 
head  and  upper  extremities  causes  the  spinal  column  to  sink  and  curve 
posteriorly.  If  the  person  is  placed  in  a sitting  posture,  the  trunk 
will  incline  forwards  from  sheer  inability  of  the  muscles  to  sustain  the 
spine  erect.  Under  the  head  of  angular  curvature  of  the  neck  the 
diagnostic  differences  of  this  deformity  and  posterior  curvature  have 
been  pointed  out,  and  they  need  not  be  repeated  here. 

The  medical  treatment  in  this  deformity  should  be  directed  to  the 
restoration  of  the  general  health,  the  re-establishment  of  muscular 
tonicity,  and  the  correction  of  any  scrofulous  or  other  constitutional 
taint  by  tonics,  nourishing  food  (eggs,  milk),  &c.  In  infants  the  hori- 
zontal position  will  generally  suffice  to  correct  the  deformity  in  a few 
weeks.  In  older  persons,  and  in  those  cases  where  the  disease  has 
made  greater  progress,  the  persistent  employment  of  mechanical  means 
; is  indispensable. 

One  of  the  best  forms  of  instrument  for  posterior  curvature  is  seen 
m Fig.  237,  at  page  314,  omitting  the  head-piece  according  to  the  cir- 


810  APPARATUS  FOR  REMEDYING  LOSS  OF  SYMMETRY 


cnmstances  of  the  case.  The  pads  should  be  placed  below  the  arc  of 
curvature. 

Mr.  T amplin  recommends  an  apparatus  (Fig.  234)  somewhat  similar, 
by  which,  at  the  same  time  that  the  weight  is  taken  oft'  the  upper  pur- 

Fig.  234. 


Tamplin’s  apparatus  for  posterior  curvature. 

tions  of  the  spinal  column,  a continued  pressure  can  be  kept  upon  the 
prominent  portion  of  the  curve  by  the  back-board  attached,  and  the 
shoulders  held  back  by  the  straps.  The  head-piece  can  be  removed 
at  will. 

Angular  Curvature  (Fig.  235). — This  deformity  results  from 
caries  of  the  bodies  of  the  vertebrae.  It  is  most  frequently  met  with  in 
children,  male  and  female  alike,  between  the  ages  of  three  and  twelve 
years,  though  it  has  been  observed  both  earlier  and  later  than  these 
periods.  Its  more  common  subjects  are  those  badly-clothed  and  fed 
persons  living  in  dark  and  ill-ventilated  hovels  in  the  narrow  streets 
and  alleys  of  our  large  cities.  The  disease  depends  often  upon  a scro- 
fulous or  tuberculous  diathesis,  and  is  then  attended  with  deposition  of 
characteristic  tuberculous  matter  in  the  osseous  tissue  and  intervene- 


OF  THE  TRUNK. 


311 


bral  cartilages  of  the  bodies  of  the  vertebrae.  In  other  instances  it 
proceeds  from  common  inflammation  of  these  parts,  set  up,  in  many 
cases,  perhaps,  by  exterior  violence  inflicted  upon  the  spine. 

Symptoms.- — During  the  formative  stage  of  the  disease  the  patient 
will  display  a general  derangement  of  the  health ; pain  in  the  back, 
at  first  slight,  will  generally  be  complained  of,  and,  as  the  disease 
progresses,  will  become  more  severe.  It  is  aggravated  by  any  rude 
or  unexpected  movement  of  the  body,  as  in  making  a false  step  or 
tripping.  From  the  irritation  of  the  spinal  cord  there  will  result  more 
or  less  derangement  of  innervation  of  the  parts  below;  the  muscles  of 
the  legs  will  contract  irregularly,  or  other  perversions  of  sensation  or 
motion  will  present  themselves.  The  patient  is  disinclined  to  take 
exercise,  from  the  sensation  of  weariness  or  weakness  which  he  feels, 
and  he  habitually  seeks  repose  in  a horizontal  position. 

As  the  ulceration  and  destruction  of  the  vertebral  substance  pro- 
ceed, the  above  symptoms  become  more  pronounced,  and  others  of  a 
more  serious  character  are  added.  The  extremities  become  cold  and 
sluggish,  and  refuse  to  respond  promptly  to  the  stimulus  of  the  will ; 
the  appetite  entirely  fails ; the  secretions  are  unhealthy ; the  respira- 
tion embarrassed ; and  the  patient  finally  becomes  emaciated,  and 
loses  control  over  the  lower  limbs,  bladder,  and  rectum.  It  is  during 
this  time  that  the  most  charac- 
teristic feature  of  the  disease  is 
developed,  namely,  an  angular 
curvature  at  some  part  of  the 
spine,  projecting  posteriorly.  It 
is  formed  by  the  spinous  pro- 
cesses, and,  as  its  name  imports, 
is  abrupt  or  pointed,  a circum- 
stance which  affords  the  surgeon 
an  important  diagnostic  mark  to 
distinguish  this  disease  from  pos- 
terior curvature  in  wrhich  these 
processes  form  an  uninterrupted 
curved  line. 

The  destruction  of  the  bodies 
of  the  vertebrae,  upon  which  the 
angularity  depends,  is  often  ac- 
companied with  the  formation  of 
considerable  purulent  accumula- 
tions at  the  point  where  the  dis- 
eased action  is  going  on,  and  the 
matter  generally  makes  its  ap- 
pearance externally  either  at  the 
loins  or  groin,  according  to  the  position  of  the  abscess. 

By  the  continual  formation  and  discharge  of  pus  the  system  is  fur- 
ther enfeebled,  and  in  such  cases  the  patients  are  commonly  worn  out 
by  constant  suffering,  and  finally  carried  off  by  hectic  and  exhaustion. 

Treatment.- — The  medical  treatment  in  angular  curvature  consists 
in  the  employment  of  tonics,  alteratives,  and  stimulants — in  fact,  those 


Fig.  235. 


312  APPARATUS  FOR  REMEDYING  LOSS  OF  SYMMETRY 

remedies  appropriate  to  remove  the  constitutional  taint  of  scrofula  or 
tuberculosis;  counter-irritation,  by  establishing  an  issue  upon  the  side 
of  the  spine,  with  the  actual  cautery,  will  also  be  of  immense  service. 

While  the  caries  is  progressing,  all  mechanical  appliances  should 
be  abstained  from,  and  the  patient  be  placed  in  the  horizontal  pos- 
ture; the  prone  being  thought  by  some  far  more  suitable  for  relieving 
pressure  upon  the  spine  and  congestion  of  the  parts  than  the  supine. 
In  regard  to  this  point,  Mr.  Tamplin  observes:  “The  plan  I usually 
adopt  is  the  following : to  request  that  the  parents  should  obtain  a 
board  somewhat  wider  and  larger  than  the  patient ; let  a horse-hair 
mattress  be  placed  upon  it,  and  let  two  circular  holes  be  made  in  it  at 
the  point  corresponding  with  the  axilla,  in  which  can  be  inserted  a 
couple  of  plugs  (one  for  each  side),  when  the  patient  is  in  the  inclined 
position,  to  prevent  them  from  slipping  down.  With  this  simple  con- 
trivance, which  is  within  the  reach  of  all,  from  the  facility  of  obtaining 
it,  a child  may  be  kept  at  rest,  the  disease  protected  from  pressure, 
and  the  angle  relieved,  or,  at  all  events,  any  increase  of  it  effectually 
prevented ; while,  at  the  same  time,  it  is  the  greatest  possible  source 
of  comfort  to  the  patients,  who,  instead  of  becoming  fretful  and  irri- 
table, with  the  health  suffering  as  a consequence,  as  might  be  antici- 
pated from  the  confinement,  actually  improve  in  health,  and  are  most 
completely  relieved  from  pain.” 

Mr.  Erichsen  prefers  the  couch  of  the  late  Mr.  Yerral,  of  London. 
In  the  construction  of  this  couch  of  two  inclined  planes  joined  at  an 
obtuse  angle,  he  supposes  that  the  twofold  object  of  removing  the 
weight  of  the  upper  part  of  the  body  from  the  spine,  and  slight  ex- 
tension of  the  spine  by  the  weight  of  the  pelvis  and  lower  extremities 
upon  the  inclined  plane,  is  obtained.  On  the  other  hand,  Mr.  Bishop 
takes  a different  view  of  the  matter,  for  he  employs  the  triple-inclined 
plane  of  Earle,  and  adopts  a recumbent  position,  occasionally  changing 
it  from  the  back  to  the  side.  He  says  that  the  result  of  a number  of 
observations  is  this — namely,  that,  in  cases  of  curvatures  of  the  spine 
arising  from  disease  and  absorption  of  the  bone,  the  distortions  do 
not  increase  while  the  body  is  kept  in  horizontal,  supine,  and  lateral 
positions,  but  they  do  increase  when  the  body  is  allowed  to  move  and 
be  erect;  and  that,  moreover,  w'hen  patients  are  confined  to  the  prone 
position,  so  far  as  his  experience  goes,  the  curve  of  the  spine  is  pro- 
gressive, for  which  there  are  obvious  mechanical  reasons.  For  instance, 
in  all  cases,  both  of  diseased  bone  and  curvature,  the  superincumbent 
pressure  cannot  be  wholly  withdrawn  in  any  oblique  position ; and 
where  the  curvature  is  in  a plane  or  planes  intermediate  between  the 
mesial  and  transverse,  as  generally  happens,  the  deformity  may  often 
be  increased  by  the  tendency  of  the  unsupported  curved  position 
towards  the  transverse  plane. 

When  the  patient  has  been  kept  in  a horizontal  position  until  an- 
chylosis of  the  diseased  vertebrae  has  taken  place,  which  will  require 
at  least  eighteen  months,  he  may  be  permitted  to  go  about  with  the 
spine  carefully  supported  by  a proper  mechanical  apparatus. 

Mr.  Tamplin  employed  for  this  purpose  an  instrument  seen  in  Fig. 
236,  consisting  of  a band  which  encircles  the  pelvis,  having  attached 


OF  THE  TRUNK. 


313 


two  crutches,  one  on  each  side,  to  support  the  shoulders,  the  crutches 
consisting  of  a male  and  female  screw,  which  enables  the  surgeon  to 


Fig.  236. 


increase  their  length,  provided  relief  is  obtained,  as  the  child  grows. 
A broad  flannel  band  should  be  passed  round  the  crutch  on  one  or 
other  side,  and  over  the  projecting  vertebra,  then  round  the  opposite 
crutch  back  again  to  the  commencement  of  the  band,  and  there  united ; 
by  this  means  an  effectual  support  is  given  without  encircling  the 
abdomen. 

If  there  should  be  need  of  the  spine  being  more  firmly  supported, 
and  the  weight  of  the  head  removed  from  it,  it  may  be  done  with  the 
instrument  (Fig.  237)  seen  in  the  annexed  woodcut,  consisting  of  a 
pelvic  strap  supporting  two  lateral  uprights  reaching  beneath  the 
axillas;  posteriorly  two  other  uprights  run  up  along  the  spine  and 
bear  at  their  apices  two  pads,  which  may  be  shifted  up  or  down,  accord- 
ing to  the  position  of  the  angle  upon  the  sides  of  which  they  repose ; 
a soft  belt  extends  between  the  pads  and  gives  support  to  the  apex  of 
the  angle.  The  vertebral  rods  support  a bifurcated  curved  metallic 
stem  which  slides  up  and  down  upon  them,  and  may  be  secured  with 
thumb-screws;  at  its  upper  extremity  it  bears  a chin  sling  and  occi- 
pital strap,  which  hold  the  head  securely.  To  give  additional  steadi- 
ness to  the  apparatus  the  pads  are  connected  by  two  lateral  straps  to 
the  crutches  of  the  axillary  supports. 


314  APPARATUS  FOR  REMEDYING  LOSS  OF  SYMMETRY 


The  apparatus  is  applied  as  seen  in  Fig.  238. 

Loss  of  Symmetry  of  the  Pelvis. — Obliquity  of  the  pelvis  is 
sometimes  a result  of  anterior  or  lateral  curvature  of  the  lumbar  ver- 
tebras, or  the  cause  may  be  in  the  pelvis  itself ; in  the  latter  instance 
the  obliquity  will  react  upon  the  spine,  and  cause  the  formation  of  two 
or  more  curves  in  it,  to  restore  the  disturbed  equilibrium  of  the  body. 
One  of  the  most  common  causes  of  this  deformity  is  irregularity  of 
length  of  the  lower  extremities  produced  by  various  agencies,  as  dis- 
ease of  the  hip  and  knee-joints. 

Young  persons  are  the  chief  sufferers,  and  in  some  of  these  cases  the 
carrying  of  heavy  loads,  the  bad  habit  contracted  by  some  children  of 
supporting  the  weight  of  the  body  upon  one  leg  while  standing,  or 
upon  one  hip  while  sitting,  will  be  found  the  causative  agents  of  nu- 
merous instances  of  pelvic  obliquity  presenting  themselves  to  the 
notice  of  the  surgeon. 

This  deviation  is  much  more  easily  prevented 
than  remedied.  The  cause  of  an  incipient  pel- 
vic obliquity  should  be  at  once  sought  out  and 
removed.  For  instance,  if  one  leg  is  shorter 
than  the  other,  by  measuring  with  a tape  line 
from  the  anterior  superior  spinous  process  of 
the  ilium  to  the  inner  malleolus,  the  difference 
in  length  should  be  at  once  made  up  by  a thick 
sole  boot. 

If  the  deformity  has  become  firmly  esta- 
blished an  effort  may  be  made  by  means  of  ad- 
hesive strips  applied  to  the  shortened  leg  and 
weighted  to  draw  dowm  the  elevated  hip ; coun- 
ter-extension can  be  made  from  the  shoulders 
by  passing  a roller  bandage  under  the  armpits 
and  fastening  them  to  the  head  of  the  bed. 

An  ingenious  contrivance  used  in  this  coun- 
try for  obliquity  of  the  pelvis,  as  seen  in  Fig 


Fig.  239. 


pelvis. 


OF  THE  UPPER  EXTREMITIES. 


315 


239,  is  composed  of  a lateral  stem  with  a check -joint  at  the  hip  pre- 
venting its  lower  part  raising  perpendicularly.  The  upper  part  of  this 
stem  projects  from  the  hip  of  the  longest  leg  to  the  axilla,  where  it 
terminates  in  a crutch,  and  is  secured  to  the  chest  by  a broad  webbing 
band ; the  lower  part  extends  from  the  stop-joint  to  beyond  the  mid- 
dle of  the  thigh  to  which  it  is  attached  by  a padded  plate ; a pelvic 
strap  gives  additional  security  to  the  instrument.  Its  action  in  cor- 
recting the  deformity  consists  in  the  drawing  outward  of  the  longer 
leg  when  a step  is  being  taken,  which  must  of  course  raise  the  hip 
and  tilt  the  pelvis  towards  the  short  leg. 

SECTION  III. 

APPARATUS  FOR  REMEDYING  LOSS  OF  SYMMETRY  OF  THE  UPPER 
EXTREMITIES. 

Deformity  of  the  Fingers. — Contraction  of  the  fingers  is  the 
deformity  with  which  the  surgeon  has  most  often  to  deal  in  the  upper 
i extremities.  It  arises  from  various  causes,  and  is  either  congenital  or 
non-congenital.  One  finger  may  be  affected  only,  or  the  whole  of 
them  at  the  same  time. 

The  congenital  cases  are  occasionally  associated  with  deformities  of 
i other  parts,  as  club-foot,  and  will  be  found  to  depend  most  alway  upon 
a shortened  condition  of  the  skin  upon  the  anterior  aspect  of  the  fin- 
| gers,  as  shown  in  the  annexed  sketches  (Figs.  210  and  241). 

Fig.  240.  Fig.  241. 


Congenital  deformities  of  the  fingers. 

2 

The  most  common  cause,  perhaps,  of  non-congenital  contraction  is 
■ thickening  and  diminution  in  the  length  of  the  palmar  fascia.  This 
condition  is  often  seen  to  a limited  extent  in  the  hands  of  old  sailors, 
and  those  engaged  in  laborious  pursuits  requiring  the  frequent  use  of 
the  hand  in  grasping  cylindrical  objects,  as  ropes,  and  the  handles  of 


316  APPAEATUS  FOE  EEMEDYING  LOSS  OF  SYMMETRY 


the  various  kinds  of  tools  used  by  artisans ; the  fascia  sometimes  even 
becomes  nodulated.  This  condition  is  shown  in  Figs.  242  and  243. 


Fig.  242. 


Fig.  243. 


Deformities  of  the  fingers  from  contraction  of  the  palmar  fascia. 


The  late  war  has  also  furnished  numerous  cases  of  this  deformity- 
originating  from  gunshot  and  incised  wounds  of  the  forearm,  hand,  or 


Fig.  244. 


Fig.  245. 


Deformity  of  the  fingers  from  wound  of  the  forearm. 


fingers.  Fig.  244  represents  a case 
of  the  kind  from  a cut  across  the 
flexors  of  the  forearm. 

Rheumatic  and  gouty  inflamma- 
tion will  produce  similar  results, 
and  in  some  of  these  instances,  be- 
sides the  contraction  of  the  fingers, 
irreparable  injury  is  also  inflicted 
upon  the  joints,  rendering  all  hope 
of  restoring  their  functions  hope- 
less. 

Contraction  of  the  skin  upon  the 
anterior  faces  of  the  fiogers  will  also  produce  and  maintain 
fingers  in  a permanently  flexed  position,  as  seen  in  Fig.  245. 


Deformity  of  the  fingers  from  contraction  of  th< 
skin. 

the 


OF  THE  UPPER  EXTREMITIES. 


317 


Lastly,  tlae  destruction  of  the  muscular  equilibrium  of  the  flexors 
and  extensors  by  paralysis  of  the  latter,  will  give  rise  to  some  of  the 
most  troublesome  cases  of  contraction  that  the  surgeon  is  called  upon 
to  remedy. 

In  the  treatment  of  this  deformity,  if  the  flexor  tendons  are  strongly 
contracted,  tenotomy  may  be  required  before  the  application  of  me- 
chanical apparatus ; while,  on  the  other  hand,  these  appliances  will 
suffice,  in  the  majority  of  cases,  alone  in  remedying  contraction  de- 
pending upon  abnormal  conditions  of  the  skin,  cellular  tissue,  and 
palmar  fascia. 

Mr.  Tamplin  frequently  availed  himself  of  the  elastic  force  of  a 
common  watch-spring,  bound  to  the  dorsal  aspect  of  the  contracted 
finger ; if  more  force  was  required  than  could  be  exercised  by  one 
spring,  two  or  three  of  them  were  fastened  together. 

The  instrument  of  M.  Duchenne,  already  described,  will  answer 
occasionally. 

In  obstinate  cases  metallic  stems,  extending  along  the  fingers, 
jointed  at  the  digital  articulations  with  ratchet-centres,  and  supported 
iupon  a metallic  plate  fitting  the  dorsum  of  the  hand,  will  have  to  be 
employed. 

Deformities  of  the  Wrist. — The  deformities  encountered  in  the 
wrist  are:  1.  Permanent  flexion  from  contraction  of  the  flexors. 
2.  Permanent  extension  from  contraction  of  the  extensors.  8.  Per- 
manent abduction  from  contraction  of  the  abductors.  The  first  form 
is  most  common.  The  causes  are  rheumatic  inflammation  about  the 
wrist-joint,  and  traumatic  injuries  and  paralysis  of  the  muscles  of  the 
brearm.  The  flexed  position  of  the  wrist  (Fig.  246)  admits  of  relief 


Fig.  246. 


>y  mechanical  apparatus,  which,  by  exercising  a gradually  extending 
orce  upon  the  parts,  brings  them  into  their  normal  position,  when  the 
pint  may  be  exercised  by  means  of  elastic  cords.  A patient  came 
mder  my  care  with  contraction  of  the  wrist  and  fingers  from  being 
fiolently  pressed  between  two  ships.  The  parts  had  been  in  this 
ondition  for  seven  months.  I applied  an  apparatus  seen  in  Fig.  247, 
3 extend  the  joint.  It  consists  of  a padded  forearm  splint,  to  which 
p attached  two  lateral  arms,  extending  to  the  basis  of  the  index  and 
ttle  fingers,  jointed  opposite  the  wrist,  and  moved  by  a ratchet-centre 
nd  key.  Extending  between  the  two  arms  across  the  dorsum  of  the 
rrist  is  a padded  plate ; a strap  encircles  the  metacarpus  to  sustain 
ie  ends  of  the  arms.  In  this  arrangement,  by  turning  the  key  of  the 
itcket-wkeel  force  is  brought  to  bear  upon  the  back  of  the  wrist  by 


318  APPARATUS  FOR  REMEDYING  LOSS  OF  SYMMETRY 


Fig.  247. 


the  padded  plate,  while  the  counter  pressure  is  made  upon  the  palm 

of  the  hand  and  forearm. 

"When  the  patient’s  hand  was  ex- 
tended, the  fingers  were  slipped  into 
a sort  of  glove,  inclosing  only  a 
narrow  portion  of  the  hand  beyond 
their  base.  To  this  border  a metallic 
strip  was  sewed,  perforated  with  four 
holes ; a wristlet  was  then  applied, 
with  a perforated  metallic  strip  also 
attached  to  its  lower  margin;  lastly, 
these  two  pieces  of  the  apparatus 
were  joined  together  by  four  elastic 
cords,  provided  with  hooks.  By  per- 
severing with  the  use  of  this  mechan- 
ism, the  functions  of  the  hand  were 
restored  in  four  months.  If  the  wrist  is  permanently  extended,  the  same 
apparatus  may  be  employed  by  simply  altering  the  position  of  the  dorsal 
plate,  which  must  now  be  made  to  press  against  the  fore-part  of  the 
wrist. 


Apparatus  for  deformity  of  tlie  wrist. 


Fig.  248. 


Permanent  abduction,  occurring  from  the  contraction  of  the  mus- 
cles upon  the  radial  border  of  the  forearm,  may  be  overcome  by  the 
following  mechanism  (Fig.  248).  Apply  to  the  forearm  a padded  me- 
tallic splint,  from  the  back  part  of  which  a short  arm  projects  as  far 
as  a sheath  fitted  to  the  lower  part  of  the  hand,  and  to  which  it  is 
fastened.  Over  the  centre  of  the  wrist  this  arm  has  a ratchet-centre, 
permitting  lateral  motion.  To  increase  the  adducting  power  still  fur- 
ther, a lever-strap,  attached  by  one  extremity  to  the  back  part  of  the 
hand-sheath,  passes  around  its  ulnar  border,  to  be  fastened  by  the 
other  to  the  posterior  surface  of  the  arm-splint. 


Fig.  249. 


OF  THE  UPPER  EXTREMITIES. 


319 


Deformities  of  the  Elbow. — The  elbow  may  become  perma- 
nently flexed  (Fig.  249),  or  permanently  extended  from  inflammation 
of  the  joint  from  any  cause — rheumatism,  contusions,  fractures,  and  the 
like,  where  the  arm  is  kept  in  a bent  position  for  a long  time.  One 
case,  coming  under  my  observation,  resulted  from  the  wheel  of  a small 
gun-carriage  passing  over  the  arm  below  the  shoulder ; no  fracture 
was  produced  nor  even  the  skin  broken. 

The  mechanical  treatment  of  these  cases  consists  in  gradually  ex- 
tending and  flexing  the  arm,  until  the  elbow  is  freely  movable,  and 
the  muscles  resume  their  functions.  The  contrivance  of  Stromeyer, 
modified  by  Mutter,  as  seen  in  Fig.  250,  is  commonly  employed  to 
make  the  extension ; the  force  being  obtained  by  an  anterior  screw 
connecting  the  upper  and  lower  splints.  This  arrangement  causes  an 
unpleasant  amount  of  pressure  at  the  upper  part  of  the  arm  and  lower 
part  of  the  forearm,  while  the  elbow  tends  to  project  posteriorly.  A 
better  form  of  apparatus  may  be  constructed  in  which  the  articula- 
tion of  the  lateral  levers  is  moved  by  a key  acting  upon  a ratchet- 
centre,  while  the  elbow  is  prevented  projecting  posteriorly  by  a padded 
strap  passing  across  it. 

Fig.  250.  Fig.  251. 


Stromeyer’s  apparatus  for  anchylosis  of  the  elbow.  Bonnet’s  apparatus  for  the  same. 

Bonnet  has  constructed  an  instrument  of  great  power  to  effect  the 
;ame  purpose  (Fig.  251),  and  it  is  superior  to  that  of  Stromeyer.  It 
insists  of  a padded  splint  fixed  to  a board,  in  which  the  arm  reposes, 
n the  centre  of  this  board  two  vertical  metallic  pins  are  placed  to 
riiich  two  lateral  levers  are  articulated  at  a point  corresponding  with 
he  centre  of  motion  of  the  elbow  and  extending  along  the  forearm 
o which  they  are  connected  by  a padded  belt.  The  joint  of  the  lever 
3 the  centre  of  a graduated  metalljc  arc  fastened  to  the  side  of  the 
j’oard  to  indicate  the  extent  of  movement,  and  bearing  a thumb-screw 
o arrest  and  hold  the  levers  at  any  desired  angle. 

Deformities  of  the  Shoulders — Contractions  of  the  shoulder- 
hut  are  of  exceedingly  rare  occurrence,  and  always  result  from 
iflammation  in  the  articulation  itself,  or  the  soft  tissues  surrounding 
j.  Chelius  recommends  the  application  of  blisters,  or  other  irritating 
bmedies,  for  the  purpose  of  inducing  absorption  of  the  interstitial 


320  APPARATUS  FOR  REMEDYING  LOSS  OF  SYMMETRY 


deposit  originating  in  rheumatic,  or  other  inflammation  of  the  soft 
parts  about  the  joint;  and  the  cautious  use  of  an  extending  apparatus. 

An  appropriate  instrument  may  be  constructed  in  the  following 
manner : Make  an  exact  mould  with  gutta  percha,  of  the  shoulder : 
and  attach  to  the  upper  and  lower  margins  two  short  metallic  pins, 
to  the  apices  of  which  two  levers  are  to  be  articulated  with  the  axis 
of  motion  corresponding  to  that  of  the  joint  itself,  by  means  of  two 
ratchet-centres  moved  with  a key.  Attach  the  levers  to  the  arm  by 
means  of  a padded  strap. 

SECTION  IV. 

APPARATUS  FOR  REMEDYING  LOSS  OF  SYMMETRY  OF  THE  LOWER 
EXTREMITIES. 

Deformities  of  the  Toes.  Contraction  of  the  Toes. — This 
deformity,  which  may  affect  one  toe  separately,  or  all  of  them  at  the 
same  time,  depends  upon  rheumatic  inflammation  of  the  small  joints, 
or  mechanical  agencies  producing  such  amount  of  irritation  as  to 
cause  permanent  contraction  of  the  flexor  muscles  inserted  into  the 
phalanges,  and  the  consequent  displacement  of  them  downwards; 
the  wearing  of  narrow,  short,  and  high-heel  boots,  for  instance,  is 
perhaps  the  most  common  cause.  Fig.  252  illustrates  the  effects  of  a 
short  boot  upon  the  great  toe,  which  is  instinctively  drawn  back  by 
the  patient  to  avoid  the  pain. 


Fig.  253  is  an  example  of  permanent  flexion  of  the  second  toe 
sometimes  called  “hammer  toe,”  which  forms  a sharp  angle  up- 
wards at  the  juncture  of  the  proximal  with  the  second  phalanx. 
Fergusson  says,  that  “ it  seems  to  occur  most  frequently  in  the  origi- 
nally well-formed  foot,  in  which  this  toe  is  a little  longer  than  the 
others ; and  though  probably  a short  shoe  is  the  chief  cause  of  the 
displacement,  I imagine  that  there  is  a natural  tendency  to  it,  from 
the  slender  shape  of  the  part  and  the  influence  of  the  flexor  and  ex- 
tensor muscles.  The  latter  seem  to  draw  the  distal  extremity  of  the 
first  phalanx  upwards  and  backwards,  whilst  the  former  apparently 
have  most  effect  on  the  furthest  end  of  the  toe,  and,  by  drawing  it 
downwards,  increase  the  displacement.”  I 

In  many  of  these  cases  of  deformities  of  the  toes  the  contractec 


Fig.  252, 


Fig.  253. 


Contraction  of  the  big  toe. 


The  “hammer  toe.” 


OF  THE  LOWER  EXTREMITIES. 


321 


flexor  tendons  will  have  to  be  divided,  after  which  a narrow  splint 
must  be  placed  beneath  the  toe  to  which  it  is  fastened  bj  a narrow 
strip  of  adhesive  plaster. 

Mr.  Tamplin  used,  as  an  extension  apparatus  for  the  great  toe,  an 
iron  plate  made  to  fit  the  sole  of  the  foot,  having  attached  to  its 
anterior  extremity  a raised  spring,  to  correspond  with  the  position  of 
the  toe ; the  splint  is  applied  by  means  of  strapping  and  bandage, 
with  which  any  degree  of  pressure  can  be  used.  Success  in  restoring 
the  joint  to  its  extended  position  generally  follows  in  the  course  of  a 
couple  of  weeks. 

I have  seen  one  case  where  all  the  toes  were  in  a position  of  forced 
extension,  occurring  in  a perfectly  healthy  person.  The  deformity 
came  on  gradually,  without  any  ascertainable  cause,  and  required 
the  tendons  of  the  extensor  to  be  cut,  and  the  toes  to  be  brought  down 
by  means  of  an  apparatus  composed  of  a metallic  plate  made  to  fit  the 
sole  of  the  foot,  from  the  anterior  part  of  which  a curved  stem  projected, 
bearing  a padded  plate  moved  vertically  by  a screw,  with  which  pres- 
sure was  brought  against  the  upper  surface  of  the  toes. 

Bunion. — This  deformity  consists  in  the  displacement  of  the  head 
of  the  first  metatarsal  bone  inwards,  while  the  proximal  phalanx  is 
pressed  outwards,  thus  making  an  angle  at  the  first  metatarso-phalan- 
geal  articulation,  and  separating  to  some  extent  the  internal  margins 
of  its  articular  surface.  It  is  always  caused  by  wearing  narrow-toed 
boots,  or  those  having  high  heels,  which  throw  a part  of  the  weight 
of  the  body  upon  the  ends  of  the  toes.  The  deformity  is  seen  in 
Fig.  254.  A similar  protuberance  is  sometimes  formed  over  the  fifth 
metatarso-phalangeal  joint.  The  mechanical  treatment  of  bunion  is 
simply  to  discontinue  the  narrow-toed  boot  and  substitute  one  with 
soft  uppers  and  with  a straight  internal  edge  from  the  heel  to  the  toe. 


Fig.  254. 


Fig.  255. 


Appearance  of  bunion.  Apparatus  for  bunion. 

An  ingenious  apparatus  is  sometimes  emphqyed  to  diminish  this 
deformity.  As  seen  in  the  figure  (255),  it  consists  of  a short  lever 
with  a ring-joint  at  its  centre,  which  reposes  upon  the  bunion ; the 


322  APPARATUS  FOR  REMEDYING  LOSS  OF  SYMMETRY 

stem  is  connected  above  to  a laced  bandage  around  tbe  instep,  and 
below  it  projects  to  the  point  of  the  toe,  which  is  drawn  out  towards  it 
by  a little  bandage. 

Deformities  of  the  Foot  and  Ankle.  Club-Foot. — This  de- 
formity consists  in  the  deviation  of  the  foot  in  various  directions  from 
the  normal  form,  and  thus  several  varieties  are  met  with,  which  are 
modifications,  more  or  less,  of  four  different  types,  viz:  talipes  varus, 
talipes  equinus,  talipes  valgus,  and  talipes  calcaneus,  named  in  the 
order  of  their  frequency. 

In  the  first  variety  or  talipes  varus  (Fig.  256)  the  foot  is  inverted, 
the  ojiter  malleolus  is  depressed,  the  heel  raised  from  the  ground,  and 

the  toes  pointed  inwards,  compelling  the 
patient  to  support  the  weight  of  his  body 
upon  the  middle  of  its  outer  border. 
The  dorsum  of  the  foot  is  more  convex 
and  the  sole  more  concave,  while  the  con- 
stant irritation  of  the  soft  parts  against 
which  the  pressure  comes  causes  them  to 
thicken,  and  a bursal  sac  to  be  formed 
in  many  cases,  which  answers  the  pur- 
pose of  a soft  cushion  to  ward  oft-  danger 
to  the  parts  below.  In  slighter  cases  of 
this  deformity  the  foot  can  be  restored 
to  its  natural  position  by  the  hands  of 
the  surgeon,  though  it  resumes  its  ab- 
normal one  immediately,  and  no  changes 
in  the  soft  tissues  or  bone  have  as  yet 
taken  place. 

Varus  is  most  always  congenital,  and 
has  been  observed  in  rare  instances  to 
be  hereditary ; in  other  cases  it  occurs  subsequent  to  birth,  and  is  caused 
by  deranged  innervation  from  teething,  convulsions,  neuralgia,  para- 
lysis, by  keeping  the  foot  in  the  same  posture  for  any  lengthy  period, 
as  may  happen  in  fractures,  wounds,  or  by  anything  which  disturbs 
continuously  the  equilibrium  of  the  muscles. 

The  changes  that  occur  in  the  parts  consist  in  elongation  of  the 
muscles  upon  the  outer  margins  of  the  leg  and  foot  and  a correspond- 
ing contraction  of  those  upon  the  inner  sides;  the  bones  of  the  tarsus, 
especially  the  os  calcis,  astragalus,  scaphoid,  and  cuboid  become  more 
or  less  separated  and  rotated  upon  their  axis  without  being  dislocated 
from  their  natural  cavities.  If  the  deformities  have  existed  for  a long 
time,  the  bones  then  alter  in  shape,  and  become  fixed  in  their  unnatural 
positions. 

Treatment. — After  the  operation,  if  tenotomy  be  required,  the  foot 
must  be  alternately  flexed  and  extended  to  break  up  all  morbid  bands 
and  adhesions,  and  an  appropriate  apparatus  applied,  which  should  be 
put  on  loosely  the  first  few  days,  uutil  the  leg  becomes  accustomed  to 
its  presence,  then  tightened  up  gradually  uutil  the  object  is  attained. 
The  instrument  must  be  worn  night  and  day.  It  will  add  much  to 
the  comfort  of  the  cure,  and  facilitate  it,  to  some  extent,  if  we  sponge 


Fig.  256. 


Talipes  varus. 


OF  THE  LOWES  EXTREMITIES. 


323 


the  leg  daily  with  the  camphorated  soap  liniment,  and  use  gentle 
friction  for  a few  minutes. 

As  to  the  selection  of  a proper  mechanical  appliance,  it  should  be 
remembered  that  the  foot  has  undergone  a threefold  alteration  in  its 
position  in  relation  to  the  leg,  being  in  exaggerated  extension,  adduc- 
tion, and  rotation,  so  that  the  indications  to  be  fulfilled  in  varus  are 
flexion,  abduction,  and  retroversion. 

An  apparatus  that  will  answer  in  most  of  the  congenital  cases,  and 
is  easily  obtainable,  may  be  prepared  by  the  surgeon  in  the  following 
manner  with  adhesive  strips,  as  recommended  by  Chelius : Take  five 
or  six  strips  of  adhesive  plaster,  long  enough  from  the  foot  to  reach 
to  just  above  the  knee,  and  about  an  inch  wide.  Have  the  foot  drawn 
into  as  natural  a position  as  possible  by  an  assistant,  then  apply  the 
strips  one  after  another,  commencing  upon  the  instep;  make  a turn 
about  it,  drawing  the  strips  around  its  outer  border,  and  then  carry 
them  up  the  leg;  to  render  the  whole  secure,  two  or  three  circular 
pieces  may  be  also  put  on.  A splint  is  now  to  be  placed  upon  the 
external  side  of  the  limb,  projecting  two  inches  beyond  the  sole  of  the 
foot,  to  which  it  must  be  bound  by  a figure  of  8 bandage. 

It  has  lately  been  the  custom  of  some  American  surgeons  to  employ 
the  elastic  force  of  India-rubber  in  the  treatment  of  club-foot.  It  ex- 
ercises a constant,  but  yielding  power  in  rectifying  the  distorted  posi- 
tion of  the  foot;  the  rubber  cords  being  put  in  such  relation  with  the 
limb  as  to  take  the  place  and  perform  the  functions  of  those  muscles 
that  have  become  abnormally  elongated  and  weakened. 

From  the  changes  that  always  ensue,  in  the  position  of  the  tarsal 
bones,  in  the  structure  of  ligaments  and  the  muscles  of  the  limb  dur- 
ing a long-continued  malposition  of  the  foot,  it  requires  patient  and 
persevering  employment  of  the  treatment  to  secure  a successful  issue. 

In  congenital  and  a certain  number  of  the  postgenital  cases  the 
present  plan  will  succeed  without  tenotomy,  yet  this  operation  is  an 
invaluable  resource  in  many  instances,  and  the  surgeon  has,  with  pre- 
sent experience,  little  ground  for  hoping  that  it  can  be  ever  altogether 
laid  aside  for  mechanical  contrivances,  as  has  been  thought  by  some. 
With  a clearer  insight  into  the  mechanism  of  club-foot  the  surgeon  will 
be  enabled  to  restrict  tenotomy  to  those  tendons  only  which  offer  an 
insurmountable  resistance  to  the  restoration  of  the  foot  to  its  normal 
posture;  he  can  thus  avoid  that  indiscriminate  cutting  of  the  various 
tissues  about  the  ankle,  often  erroneously  supposed  to  participate  in 
the  causation  of  the  deformity,  which  has  been  practised  in  too  many 
cases  unnecessarily,  with  permanent  injury  to  the  patient. 

Even  in  those  cases  apparently  insurmountable,  by  the  persevering 
use  of  elastic  traction,  success  may  be  obtained,  at  least  by  assisting  the 
action  of  the  rubber-cords  with  force  judiciously  applied  with  the 
hands,  while  the  patient  is  under  the  influence  of  an  anaesthetic. 

As  the  tractile  cords  are  intended  to  supplement  the  impaired  power 
of  the  muscles,  they  should  be  made  to  act  as  nearly  as  possible  in  the 
line  of  the  muscles  thev  represent. 

To  attain  this  object  Mr.  Barwell  has  suggested  an  ingenious  plan 
of  fastening  them  to  the  limb.  In  order  to  get  an  upper  point  of 


324  APPARATUS  FOR  REMEDYING  LOSS  OF  SYMMETRY 

attach raent  he  secures  to  the  leg  an  oblong  piece  of  tin  by  taking  a lont* 
strip  of  adhesive  plaster,  and  applying  half  of  its  length  to  the  tibia 
from  the  knee  to  just  above  the  ankle;  the  strip  of  tin,  which  should 
be  a little  narrower  than  the  adhesive  plaster,  is  laid  upon  this,  then 
the  free  end  of  the  strip  is  carried  up  in  front  of  the  tin,  with  its 
adhesive  side  looking  forwards;  a roller  bandage  or  circular  strips 
of  plaster  should  now  be  applied  to  the  leg,  and  the  terminal  end  of 
the  strip  brought  down  over  the  bandage  so  as  to  secure  all.  A wire 
loop  is  inserted  into  the  upper  end  of  the  tin. 

The  lower  point  of  attachment  is  established  by  applying  across  the 
bottom  of  the  foot  a trapezoid  piece  of  adhesive  plaster,  with  an  eyelet 
in  one  of  its  corners  ; it  is  secured  to  the  part  by  circular  strips  of  the 
same  material. 

The  rubber  spring  is  stretched  between  these  two  points  above  and 
below  by  means  of  catgut  cords.  In  talipes  valgus  the  tin  will  be 
placed  upon  the  anterior  surface  of  the  tibia,  and  but  one  elastic  cord 
need  be  used,  extending  in  the  direction  of  the  tibialis  anticus,  be- 
tween the  wire  loop  at  the  upper  end  of  the  tin  plate  and  the  eyelet 
in  the  plaster.  In  talipes  varus  the  tin  is  secured  just  behind  the 
fibula,  and  two  traction  cords  are  employed ; the  anterior  one  passing 
in  front  of  the  external  malleolus,  and  representing  the  peroneus  ter- 
tius,  the  posterior  behind  the  malleolus,  in  the  direction  of  the  pero- 
neus longus  and  brevis. 

In  cases  in  which  the  patient  has  walked,  the  weight  of  the  body 
upon  the  margin  of  the  foot  approximates  the  external  and  internal 
arches  of  its  sole ; in  other  words,  produces  a longitudinal  folding, 
which  becomes  gradually  effaced  by  the  same  cause  that  produced  it, 
namely,  the  weight  of  the  body  after  the  foot  has  been  sufficiently 
abducted  by  the  above  described  plan  of  treatment. 

Dr.  David  Prince,  of  Illinois,  has  suggested  a simple  and  efficient 
method  of  accomplishing  the  same  object  with  the  following  contriv- 
ance : “ For  a patient  ten  years  old  take  a sheet  of  gutta-percha  one- 
third  of  an  inch  thick,  or  a sufficient  number  of  thinner  sheets  to 
make  that  thickness,  long  enough  to  encircle  the  foot,  and  wide  enough 
to  extend  from  the  middle  joint  of  the  phalanges  to  the  medio-tarsal 
articulation,  i.e.,  the  joint  between  the  scaphoid  and  astragalus  above, 
and  the  cuboid  and  calcaneum  below. 

“Apply  upon  both  surfaces  of  the  gutta-percha  an  investment  of 
muslin  of  good  strength,  and  lay  the  whole,  thus  prepared,  into  a pau 
of  water  nearly  boiling  hot.  While  the  softening  process  is  going  ou 
the  foot  should  be  wrapped  with  a roller,  protecting  the  prominent 
points  with  pledgets  of  lint  or  cotton. 

“As  soon  as  the  gutta-percha  is  thoroughly  softened,  it  is  taken  out, 
still  lying  between  its  muslin  investments,  and  so  applied  that  its  ends 
come  together  on  the  outside  of  the  foot  (in  talipes  varus),  where  the 
two  extremes  of  gutta-percha  should  be  welded  by  pressure  between 
the  thumb  and  fingers,  previously  dipped  into  cold  water,  to  keep  the 
material  from  sticking  to  the  fingers. 

“In  talipes  valgus,  the  extremities  of  the  gutta-percha  meet  and  pro- 
ject on  the  inner  or  median  side  of  the  foot.  While  the  material  is  yet 


OP  THE  LOWER  EXTREMITIES. 


325 


warm  and  yielding,  a square  piece  of  pasteboard  is  laid  upon  the 
dorsal  surface  of  the  foot,  with  a corresponding  piece  of  oiled  silk  or 
rubber-cloth  underlying  it  to  prevent  its  softening  by  the  moisture  of 
the  wet  muslin  investment,  and  a similar  piece  of  pasteboard  is  applied 
directly  opposite  upon  the  plantar  surface. 

“A  common  pair  of  calipers,  with  screw  fastening,  is  then  applied, 
so  that  one  leg  rests  upon  the  pasteboard  upon  the  dorsal,  and  the 
other  upon  the  pasteboard  upon  the  plantar  surface.  The  screw  is 
then  turned,  to  secure  very  firm  squeezing  between  the  opposing  points. 
This  compression  is  continued  until  the  gutta-percha  has  become  hard 
and  unyielding,  except  by  its  elasticity.  After  this,  the  calipers  are 
removed. 

“A  hole  is  then  punched  through  the  projecting  gutta-percha,  along- 
side of  the  metatarsal  bone  of  the  little  toe  in  varus,  and  of  the  great 
toe  in  valgus.  Into  this  hole  a cord  is  inserted,  which  is  fastened  to 
a rubber  ribbon  or  piece  of  rubber  tube  or  cylinder,  which  must  again 
have  its  attachments  above  by  adhesive  bands  below  the  knee,  above 
the  knee,  or  by  a padded  roll  to  the  pelvis,  which  is  thereby  encircled. 
This  last  is  the  least  troublesome  attachment,  as  it  can  at  any  time  be 
slipped  off  and  put  on  again.  In  the  last  method,  a knee-cap  is  neces- 
sary to  make  the  tension-cord  follow  the  angle  of  the  limb  in  walk- 
ing and  sitting.  The  appliance  to  the  foot  should  be  removed  and 
reapplied  every  day  in  hot  weather,  and  every  alternate  day  in  cold 
weather,  to  avoid  excoriation  from  pressure  and  retained  exhalations.” 

Dr.  Alfred  C.  Post  extols  the  gutta-percha  shoe  in  the  treatment  of 
talipes.  The  material  of  which  he  constructs  these  shoes  “is  a gutta- 
percha sheet  from  a sixteenth  to  an  eighth  of  an  inch  in  thickness. 
It  is  cut  of  such  a shape  as  to  adapt  itself  to  the  sole  and  sides  of  the 
foot,  leaving  a space  uncovered  on  the  dorsum  of  the  foot  equal  to 
about  one-third  of  the  breadth  of  the  foot;  it  is  also  adapted  to  the 
sides  of  the  leg,  extending  up  two-thirds  of  the  distance  to  the  knee, 
and  leaving  a narrow  space  uncovered  before  and  behind,  each  space 
so  uncovered  being  about  one-sixth  of  the  circumference  of  the  leg. 
The  material  is  readily  moulded  to  the  shape  of  the  limb  by  immersing 
it  for  a few  seconds  in  water  at  a temperature  of  100°  Fahrenheit.  He 
is  in  the  habit  of  moulding  the  shoes,  thus  heated,  over  a wooden  last 
made  for  the  purpose.  The  last  is  not  made  after  the  fashion  of  a 
bootmaker’s  last,  but  it  is  shaped  like  the  natural  leg  and  foot,  except 
that  the  outer  side  of  the  foot  is  made  to  correspond  with  the  inner, 
thus  obviating  the  necessity  of  having  separate  lasts  for  the  right  and 
left  foot.” 

He  generally  commences  the  treatment  of  infantile  club  foot  by 
the  subcutaneous  division  of  the  tendo-Achillis,  after  which  he  applies 
a strip  of  isinglass  plaster  over  the  small  wound  of  the  skin.  He  then 
has  the  foot  held  by  an  assistant  as  nearly  as  possible  in  its  normal 
position,  and  while  it  is  so  held  he  carefully  applies  a roller  bandage  so 
as  to  cover  the  foot  and  leg,  beginning  the  application  on  the  outer 
side  of  the  ankle.  He  then  applies  the  gutta-percha  shoe,  an  assistant 
grasping  the  leg  with  one  hand,  pressing  the  upper  part  of  the  shoe 
against  the  sides  of  the  limb,  and  with  the  other  hand  pressing  the 


326  APPARATUS  FOR  REMEDYING  LOSS  OF  SYMMETRY 


sole  of  the  shoe  against  the  sole  of  the  foot.  While  the  shoe  is  thus 
firmly  pressed  against  the  leg  and  foot,  he  applies  a roller  bandage 
firmly,  so  as  to  secure  it  in  its  place.  After  the  lapse  of  twenty-four  to 
forty-eight  hours  he  takes  off  the  bandages  and  shoe,  washes  the  foot, 
wipes  it  dry,  uses  passive  motion  freely  in  different  directions,  and  then 
reapplies  the  apparatus  as  before.  The  application  is  repeated  at  inter- 
vals of  two  or  three  days,  until  the  foot  is  brought  to  its  proper  shape, 
■when  it  is  put  up  in  a laced  boot,  lacing  to  the  toes,  and  having  a firm 
sole  and  stiff  sides,  provided  with  iron  braces  which  extend  nearly  as 
high  as  the  knee,  and  secured  by  a strap  and  buckle  around  the  upper 
part  of  the  leg. 

Good  sole-leather,  pasteboard,  tin,  or  some  similar  material,  may 
be  moulded  to  the  limb  in  the  same  manner,  forming  serviceable  and 
efficient  splints. 

Various  other  contrivances  for  the  treatment  of  club-foot  have  been 
introduced  to  the  notice  of  the  profession,  from  time  to  time,  by  various 
surgeons  and  surgical  instrument  makers;  all  of  them  being  modifi- 
cations, of  greater  or  less  merit,  of  “ Scarpa’s  shoe.”  The  apparatus 
of  this  surgeon  is  rather  complex,  consisting  of  a thinly-padded  me- 
tallic sole,  to  the  posterior  portion  of  which  a semicircular  piece  of 
metal  is  attached,  to  embrace  the  heel  above  its  point ; a side-stem  is 
connected  with  the  heel-piece  by  ratchet  centres  in  such  a manner  as 
to  permit  antero-posterior  and  lateral  motions  at  points  corresponding 
with  the  ankle ; a curved  spring  also  projects  from  the  heel-piece 
along  the  inner  side  of  the  shoe,  which  is  intended,  by  its  pressure,  to 

straighten  the  foot.  The  apparatus  is 
connected  to  the  limb  by  a metallic  strap 
placed  at  the  top  of  the  side-stem,  to  en- 
circle the  leg  below  the  knee,  and  by  a 
number  of  leather  straps  and  buckles. 

A more  simple  and  efficient  apparatus 
is  the  one  seen  in  Fig.  257,  designed  by 
Mr.  Kolbe,  of  Philadelphia.  It  consists  of 
two  lateral  metallic  straps  jointed  at  the 
knee  and  ankle,  extending  from  the  lower 
third  of  the  thigh  to  a shoe  of  peculiar  con- 
struction. They  are  movable  upon  each 
other,  so  that  the  instrument  may  be 
adapted  to  limbs  of  different  lengths,  and 
are  connected  to  the  leg  by  three  padded 
metallic  straps,  one  encircling  the  thigh, 
and  the  other  two  the  leg.  The  shoe  is 
composed  of  a lacing  upper  of  soft  lea- 
ther, attached  to  a metallic  sole  divided 
into  two  sections,  and  movable  laterally 
upon  each  other  at  a point  corresponding 
with  the  medio-tarsal  articulation,  that  is 
at  the  junction  between  the  os  calcis  with  the  cuboid  bone  below,  and 
the  astragalus,  with  the  scaphoid,  above.  The  mechanism  of  motion 


Fig.  257. 


Kolbe’s  club-foot  apparatus. 


OF  THE  LOWER  EXTREMITIES. 


327 


is  simply  a ratchet  arrangement  concealed  in  the  sole  of  the  shoe,  and 
controlled  by  a key  fitting  to  a screw-head  placed  upon  its  margin. 

A short  screw  extends  between  the  side-stem  and  the  shoe,  to  move 
the  latter  antero-posteriorlv  upon  a joint  placed  in  the  lateral  stems  at 
a level  with  the  tibio-astragalal  articulation. 

When  the  instrument  is  applied  the  foot  is  firmly  secured  in  the 
shoe  by  a broad  strap  encompassing  the  limb  above  the  malleoli,  and 
connected  with  the  metallic  sole  by  three  smaller  straps  at  its  poste- 
rior and  lateral  sides. 

There  is  no  provision  for  lateral  motion  at  the  ankle,  as  in  the  con- 
trivance of  Scarpa;  a complication  of  the  apparatus  that  is  entirely 
unnecessary,  inasmuch  as  the  foot  can  readily  be  abducted  with  the 
hand  before  it  is  encased  in  the  shoe.  The  instrument  is  constructed 
with  a view  of  first  converting  a talipes  varus  into  a talipes  equinus, 
and  then  bringing  down  the  heel  into  its  normal  position. 

Dr.  Little,  of  London,  has  also  invented  a contrivance  (Fig.  258)  for 
varus.  It  is  constructed  with  a padded  metallic  shoe,  to  which  one  side- 

Fig.  258.  Fig.  259. 


Dr.  Little's  club-foot  apparatus.  External  and  internal  views. 


stem  for  the  perineal  edge  of  the  leg  is  movably  articulated ; the  move- 
ment of  flexion  between  them  being  controlled  by  a long  screw  ex- 
tending between  the  stem  and  heel  of  the  shoe.  The  foot  is  secured 
in  the  shoe  by  a broad  belt  passing  over  the  metatarsus,  and  two 
straps  crossing  the  instep.  A padded  strap  connects  the  side  lever 
to  the  leg  below  the  knee,  while  another  strap,  placed  above  the 
malleoli,  and  connected  by  two  straps  to  the  shoe,  prevents  the  heel 
rising  vertically.  The  broad  strap  seen  in  the  figure,  running  between 
the  upper  strap  and  shoe,  is  intended  to  check  any  sudden  abduction 


328  APPARATUS  FOR  REMEDYING  LOSS  OF  SYMMETRY 


of  the  foot.  When  the  screw  is  turned,  the  heel  is  gradually  brought 
down,  there  being  no  further  provision  made  to  correct  the  adduction, 

while  rotation  is  in  some  de- 
F,g'  260‘  gree  corrected  by  the  ankle- 

straps. 

A modification  of  this  instru- 
ment (Fig.  260).  sometimes  em- 
ployed, has  a horizontal  lever 
reaching  to  the  point  of  the  big- 
toe  from  the  heel  of  the  shoe,  and 
bearing  a strap  at  its  extremity 
to  encircle  the  metacarpus,  and 
by  its  pressure  abducting  the  an- 
terior part  of  the  foot. 

Talipes  Equinus. — This  de- 
formity, seen  in  Figs.  261,  262, 
consists  in  a permanent  contrac- 
tion of  the  gastrocnemius  and 
soleus  mucles,  raising  the  heel 
from  the  ground  to  a greater  or 
less  extent,  and  bringing  the  foot, 
the  dorsum  of  which  is  unusually 
„ convex,  with  a corresponding  con- 

Dr.  Little  s apparatus  modified.  . . , , 1 . ° 

cavity  in  the  sole,  nearly  to  a 
straight  line  with  the  leg,  the  weight  of  the  body  being  borne  upon 
the  metatarsus  and  toes.  In  most  cases,  however,  the  foot  inclines  some- 


Fig.  261. 


Fig.  262. 


Talipes  equinus.  External  and  internal  views. 


what  inwards  or  outwards;  and  when  this  occurs  to  any  extent,  it 
merges  into  the  varieties  called  equino-varus  and  equino- valgus. 

In  children  talipes  equinus  is  caused  by  the  irritation  of  teething,  and 


OF  THE  LOWER  EXTREMITIES. 


329 


worms ; in  adults,  by  wounds  of  the  leg,  scrofulous  disease  of  the  joint, 
and  rheumatism.  According  to  Mr.  Tamplin,  it  is  rarely  congenital.  The 
principal  displace- 
ment of  the  tarsus  is  Fig.  263. 

a depression  of  the 
scaphoid  and  the 
projection  of  the 
head  of  the  astrag- 
alus upon  the  top  of 
the  foot,  while  the 
tibia  is  displaced 
backward  upon  the 
facet  of  the  astrag- 
alus. 

Treatment. — This 
form  of  club-foot  is 
perhaps  the  easiest 
to  treat  mechanic- 
ally, the  indication 
(being  to  draw  down 
the  heel  after  the  di- 
vision of  the  tendo-  Stromeyer’s  apparatus  for  club-foot. 

lAchillis. 

One  of  the  earliest  apparatus  employed  for  this  purpose  was  what 
is  known  as  “ Stromeyer’s  foot-board.”  It  consists,  as  seen  in  Fig. 
263,  of  a posterior  splint  which  is  fastened  to  the  posterior  surface 
of  the  leg  by  straps;  to  its  lower  part,  a foot-board  is  attached  by  an 
axis,  permitting  vertical  motion,  and  moved  by  cords  winding  around 
a windlass,  situated  at  the 


bottom  of  the  splint.  The  ac- 
tion of  the  instrument  forces 
up  the  toes,  and  the  heel  de- 
scends in  an  equal  ratio. 

When  applied  to  the  foot 
'the  patient  cannot  move  about, 
as  is  easily  seen  by  the  con- 
struction of  the  apparatus. 

A modification  of  “ Stro- 
meyer’s foot-board,”  by  Lis- 
ton, is  seen  in  Fig.  264. 

It  is  formed  of  a metallic 
shoe  with  a lacing  upper,  to 
the  sides  of  which  two  leg- 
. stems  are  movably  attached, 
ind  connected  above  by  a 
aadded  strap.  A second  strap 
crosses  the  instep  to  prevent 
be  heel  ascending  vertically. 
The  instrument  acts  by  mak- 
ng  afulcrum  over  the  astraga- 


Fig.  264. 


Liston’s  apparatus. 


330  APPARATUS  FOR  REMEDYING  LOSS  OF  SYMMETRY 

lus  by  the  instep  strap,  and  a point  of  resistance  at  the  metatarso- 
phalangeal articulation;  force  now  applied  to  the  levers  will  neces- 
sarily cause  the  heel  to  descend. 

The  first  instrument  described  for  the  treatment  of  varus  is  also 
arranged  in  such  a manner  that  it  may  be  used  for  equinus. 

Talipes  yalgus  is  the  contrast  of  varus,  and  much  less  common 
than  either  of  the  two  former  varieties  of  these  deformities.  The  foot 
is  everted,  the  heel  drawn  up,  the  toes  elevated,  and  the  weight  of  the 
body  is  supported  upon  its  inner  margin ; it  has  in  fact  become  ab- 
ducted, flexed,  and  rotated  outwards. 

The  changes  in  the  directions  of  the  bones,  in  a case  examined  by 
Dr.  Little,  were : “ The  astragalus  is  twisted  in  such  a manner  that  the 
articular  facet,  which  ought  to  be  applied  against  the  inside  of  the 
internal  malleolus,  did  not  enter  the  composition  of  the  ankle-joint, 
but  was  turned  downwards;  the  navicular  bone  and  calcaneum 
followed  the  astragalus,  and,  together  with  the  internal  malleolus, 
would  have  touched  the  ground  with  their  internal  surfaces,  if  the  feet 
bad  belonged  to  subjects  who  could  have  walked.  The  external  edge 
of  the  os  cuboides,  and  fifth  metatarsal  bone,  and  external  surface  of 
the  calcaneum  presented  directly  upwards ; the  latter,  therefore,  was 
in  contact  with  the  external  malleolus,  the  prominence  of  which  could 
not  be  felt  through  the  foot.” 

Valgus  is  generally  produced  by  traumatic  injuries,  and  is  seldom 
congenital. 

Treatment. — After  the  division  of  the  tendons  of  the  peroneus  longus 
and  brevis,  and  the  extensor  communis,  if  it  be  necessary,  the  proper 
mechanical  apparatus  for  counteracting  the  deformity  consists  of  a 
simple  splint  extending  from  the  knee  to  the  inner  malleolus,  from 
the  lower  extremity  of  this  a spring  projects  along  the  inner  border 
of  the  foot,  having  a soft  pad  attached  to  it  to  make  pressure  beneath 
the  scaphoid ; the  end  of  the  spring  is  bound  to  the  forepart  of  the 
foot  by  a bandage  or  strip  of  adhesive  plaster.  With  this  apparatus 
gradually  raise  the  arch  of  the  foot,  vrhen  an  ordinary  shoe  with  a pad 
fastened  to  the  inside  of  it,  at  the  inner  margin  of  the  sole,  may  he 
worn.  The  apparatus  of  Kolbe  is  also  adapted  to  the  treatment  of 
valgus. 

As  the  method  of  treating  varus  with  elastic  cords  has  already  been 
fully  explained,  it  is  simply  necessary  to  remark  in  this  place  that  the 
same  mode  may  also  be  adopted  in  valgus,  the  only  modification  re- 
quired being  that  the  cords  must  be  made  to  act  upon  the  inner  margin 
of  the  foot  instead  of  the  outer,  as  in  varus. 

In  simple  yielding  of  the  instep  inwards,  constituting  splay-foot,  a 
shoe  with  an  India-rubber  pad  to  rest  beneath  the  scaphoid  will  be  of 
great  service.  Some  recommend  that  a curved  metallic  spring  be  in- 
troduced in  the  sole  of  the  boot  lengthwise  the  arch,  but  this  is  not  so 
good  as  the  pad. 

Talipes  Calcaneus. — This  form  of  club-foot  was  so  named,  by 
Dr.  Little,  because  the  heel  alone  rested  upon  the  ground  (Fig.  2651, 
while  the  rest  of  the  foot  stuck  upwards,  forming  a more  or  less  acute 
angle  with  the  leg.  This  deformity  is  always  congenital,  and  when  seen 


OF  THE  LOWER  EXTREMITIES. 


331 


immediately  after  birth  the  foot  may  be  easily  restored  to  its  natu- 
al  position.  It  is  accompanied  with  little  or  no  displacement  of 
he  tarsal  bones.  A simple  contrivance  for  correcting  the  defor- 
nity  will  be  found  in  the  application  of  a splint  made  of  gutta- 
)ercha  moulded  to  the  back  of  the  leg  and  sole  of  the  foot  while  they 
.re  in  a rectangular  position. 

A more  complicated  and  expensive,  but  no  less  efficient  appa- 
ratus for  talipes  calcaneus,  is  seen  in  Fig.  266,  which  is  constructed 


Fig.  265. 


Appearance  of  talipes  calcanens. 


Fig.  266. 


Fig.  267. 


vith  two  metallic  side-stems  articulated  at  the  knee  and  ankle,  and 
iionnected  to  the  limb  with  padded  metal  straps ; they  are  connected 
oelow  to  the  sole  of  a lacing  shoe.  Above  ancl  below 
he  ankle-joint  two  metallic  rods  arch  over  the  posterior 
nargin  of  the  leg  between  the  side-stems,  to  which  they 
ire  strongly  riveted,  and  are  connected  on  the  posterior 
nedian  line  by  a spiral  spring,  which  constantly  exerts 
in  extending  power  upon  the  foot.  The  spiral  spring 
nay  be  replaced  advantageously  by  an  elastic  cord. 

In  all  cases  of  club-foot  after  the  deformity  has  been 
mtirely  overcome  by  appropriate  apparatus,  it  will  be 
veil  to  exercise  the  foot  for  some  time  with  an  ordinary 
I hoe  (Fig.  267),  with  two  lateral  stems  ascending  to  a 
)oint  below  the  knee,  and  articulated  at  the  ankle-joint. 

Bowed  or  Bandied  Legs. — In  this  deformity,  seen  in 
Fig.  268,  the  knees  are  widely  separated  from  each  other 
md  the  legs  curved  outwardly,  which  gives  the  patient  an 
awkward  waddling  gait;  there  is  more  or  less  weakness  of 
he  limbs,  and  fatigue  in  using  them,  for  the  reason  that  the 
weight  of  the  body  is  not  supported  in  the  line  of  their  axis. 

This  condition  does  not  depend,  as  knock-knee,  upon  a yielding  of  the 
igaments  of  the  knee-joint,  but  upon  a curvature  of  the  bones  of  the  leg 


Shoetobe  worn 
in  club-foot  after 
the  deformity 
has  been  recti- 
fied. 


332  APPARATUS  FOR  REMEDYING  LO.SS  OF  SYMMETRY 


Appearance  of  bowed  legs. 


Fig.  269. 


Fig.  270. 


Fig.  268.  itself — the  tibia  ancl  fioula — which,  in  children  of 

an  unhealthy  constitution  and  surrounded  by  bad! 
hygienic  influences,  are 'often  affected  with  rachitic 
softening,  in  consequence  of  the  altered  proportions 
of  the  calcareous  and  animal  constituents  of  the 
bone.  The  legs,  thus  rendered  unable  to  support 
the  weight  of  the  body,  generally  yield  outwards, 
though  sometimes  forwards,  or  in  both  of  these 
directions — forwards  and  outwards — at  the  same 
time. 

In  rare  cases  it  affects  but  one  leg,  the  other 
leg  being  curved  inwards. 

Treatment. — The  general  treatment  with  tonics 
and  alteratives  should  be  directed  to  the  improve- 
ment of  the  constitution,  while  mechanical  means 
should  be  employed  to  straighten  the  legs.  This 
can  be  accomplished  in  eighteen  months  or  two 
years,  among  children  to  whom  the  deformity  is 
always  confined.  After  the  body  has  acquired  its 
normal  stature,  and  the  bones  acquired  solidity, 
little  can  be  accomplished  in  the  way  of  cure. 

A simple  appliance,  that  will  be  found  as  efficient  as  any,  is  seen  in  the 
annexed  drawing  (Fig.  269).  It  is  a well-padded  splint  extending  from 

the  condyle  of  the  femur  to  below 
the  malleolus,  along  the  inner  side 
of  the  leg,  to  which  it  is  bound  by 
two  straps ; three  other  straps  pass 
around  the  splint  and  leg  at  the  top 
of  the  curvature,  intended  to  depress 
the  arch  formed  by  the  curve  of  the 
tibia  and  fibula,  while  its  abutments 
at  the  knee  and  ankle  are  sustained 
by  the  ends  of  the  splint. 

Mr,  Kolbe,  of  Philadelphia,  has 
devised  the  apparatus  seen  in  Fig. 
270,  for  bowed  leg.  It  is  constructed 
of  two  metallic  side-stems  jointed 
at  the  knee  and  ankle,  connected 
above  to  a padded  metal  plate  in- 
closing the  lower  part  of  the  thigh 
and  below  to  a laced  boot.  These 
stems  are  sufficiently  flexible  to  he 
bent  so  that  the  instrument  may  he 
accommodated  to  the  curvature  o: 
auy  limb,  how  great  soever  it  may 
be.  Upon  the  inner  stem  there  are 
placed  two  pads,  one  above,  to  rest  upon  the  head  of  the  tibia,  the  othei 
below,  to  occupy  a position  over  the  inner  aspect  of  the  ankle ; these 
are  intended  as  points  of  counter-pressure  to  the  force  exerted  directly 
over  the  arc  of  curvature  by  the  oval  pad  moving  from  the  mid 


Apparatus  for  bowed  legs. 


OF  THE  LOWER  EXTREMITIES. 


333 


Apparatus  for  anterior  cur- 
vature of  the  leg. 


He  of  the  outer  vertical  stem  by  means  of  two  Fig-  271. 

■crews. 

In  anterior  curvature,  alluded  to  above,  an 
ppropriate  apparatus  will  be  found  in  the  con- 
rivance  seen  in  the  annexed  wood-cut  (Fig.  271), 
consisting  of  two  metallic  stems  jointed  at  the 
nkle,  and  connected  below  to  the  sole  of  a laced 
>oot,  and  above  to  a metallic  padded  strap, 
rhich  encircles  the  leg  below  the  knee ; between 
he  side-stems  two  broad  pieces  of  leather  extend 
.nteriorly  across  the  convexity  of  the  curved  leg, 

,nd  they  are  closed  in  front  by  a lacing  cord 
unning  through  their  eyeleted  margins. 

CONTRACTIOX  OF  THE  KXEE-JoiXT. — Contrac- 
ion  of  the  knee-joint,  as  the  name  implies,  is  the 
permanent  bending  of  the  leg  upon  the  thigh  at 
:,n  angle.  Its  extent  may  vary  from  the  slightest  bend  of  the  limb  to 
he  formation  of  a right  or  even  an  acute  angle;  and  exists  alone  or  may 
;>e  accompanied  with  contraction  of  the  flexors  or  adductors  of  the 
high,  or  with  contraction  of  the  muscles  of  the  calf  of  the  leg ; in 
-ertain  cases  the  tibia  may  be  displaced  a little  laterally  or  poste- 
iorly,  even  rotated  upon  the  femur,  all  of  which  complications  will 
■>e  considered  under  separate  headings  below,  with  the  apparatus  ap- 
iropriate  to  their  treatment. 

This  deformity  is  caused  by  contraction  of  the  hamstring  muscles 
rom  paralysis,  inflammation  of  the  knee  from  rheumatism  and  injuries, 
y contraction  and  consolidation  of  the  liga- 
ments and  fibrous  tissues  about  the  joints, 
ervous  irritation,  as  in  hysteria,  and  by 
•sseous  anchylosis. 

Two  plans  of  treatment  are  pursued  : in 
ae  first,  the  patient  is  laid  upon  his  face, 
nd  the  surgeon,  seizing  the  foot  of  the  dis- 
)rted  leg  in  his  right  hand,  and  steadying 
ae  thigh  with  his  left,  forcibly  extends 
he  limb.  In  the  second,  the  limb  is  moved 
y gradual  extension  by  means  of  appara- 
as  either  with  or  without  tenotomy. 

When  the  contraction  is  in  the  mesial 
ne  the  instrument  that  will  be  found  as 
Fcient  as  any  other  is  shown  in  the  wood- 
at  (Fig.  272),  and  was  designed  by  Kolbe. 

!'  is  constructed  with  padded  metallic 
ugh  and  leg  splin.ts,  connected  by  two 
.teral  levers,  articulations  corresponding 
ith  the  axis  of  motion  of  the  knee-joint. 

7hen  the  force  is  applied  by  the  screw 
mnecting  the  splint  posteriorly,  the  knee  is  prevented  from  springing 
rwai'd  by  a padded  ring  placed  over  the  patella  and  connected  to  the 


Fig.  272. 


Apparatus  for  contraction  of  the  knee. 


334  APPARATUS  FOR  REMEDYING  LOSS  OF  SYMMETRY 

upper  and  lower  splints  by  four  straps,  and  which  form  a fulcrum,  or 
point  of  resistance,  while  the  splints  exercise  pressure  upon  the  an- 
terior surface  of  the  thigh  and  leg. 

M.  Bonnet  used  the  apparatus  seen  in  Fig.  273  for  the  purpose  of 
restoring  the  functions  of  extension  and  flexion  to  the  knee-joint.  It 


Fig.  273. 


is  composed  of  two  lateral  rods  connected  beneath  the  sole  of  the 
foot,  and  extending  up  the  sides  of  the  limb  to  the  upper  part  of  the 
thigh,  and  jointed  at  the  knee;  the  rods  are  joined  posteriorly  by  broad 
metallic  troughs  to  support  the  leg  and  thigh,  and  to  which  they  are 
attached  by  anterior  splints,  buckles  and  straps.  To  sustain  the  limt 
at  the  proper  elevation  while  it  is  being  exercised,  two  strong  rods 
project  from  the  thigh-piece  to  a triangular  frame  which  support.- 
them. 

The  motion  is  impressed  upon  the  limb  by  a lever  which  is  attachec 
to  the  side-rods  of  the  leg-piece  beneath  the  knee:  this  is  used  to  fles 
the  leg;  an  extending  cord  runs  from  the  arched  portion  of  the  in 
strument  beneath  the  foot,  over  a pulley  placed  upon  the  supporting 
frame,  and  is  held  in  the  patient’s  hand ; with  this  the  leg  is  ex 
tended. 

The  manner  of  applying  and  using  the  apparatus  is  shown  in  Fig 
273. 

Mr.  Tamplin  invented  an  appliance  (Fig.  274)  to  meet  the  indiea 
tions  in  that  class  of  cases  presenting  lateral  displacement  along  wit! 
flexion.  It  consists  of  leg  and  thigh  splints  connected  together  poste 
riorly  by  a stem,  with  an  articulation  admitting  of  antero-posterio 
and  lateral  movements ; the  poiver  is  applied  by  two  screws,  one  upo: 
the  posterior  and  the  other  upon  the  lateral  plane  of  the  spdints;  tli 
knee  is  prevented  springing  forward  by  a knee-cap.  Its  action  i 


OF  THE  LOWER  EXTREMITIES. 


335 


similar  to  the  one  described  above,  with  the  difference  that  it  has 
also  lateral  action. 


nethod  of  remedying  this  is  to  place  the  patient  in  a horizontal  posi- 
tion, and  make  extension  and  counter-extension  upon  the  leg  until  the 
lead  of  the  tibia  is  brought  down,  and  then  to  apply  an  apparatus  to 
'etain  it.  For  the  latter  purpose,  Mr.  Erichsen  speaks  flatteringly  of 
tn  appliance  designed  and  constructed  by  Mr.  Bigg,  of  London.  He 
bus  describes  it : “A  and  B are  two  levers,  composed  of  metal,  corre- 
sponding in  their  direction  to  the  perpendicular  position  of  the  femur 
md  tibia.  C and  D are  two  axes,  placed  exactly  coincident  with  the 
centres  of  the  articular  ends  of  the  bones.  E and  F are  two  powerful 
prings,  whose  action  takes  place  in  opposing  directions,  similar  to  the 
j.rrow  indications  in  Fig.  276.  This  F presses  the  lever  B in  an  ante- 
ior  direction,  bearing  the  end  of  the  tibia  forward ; whilst  E presses 
he  lever  A in  a posterior  direction,  bearing  the  end  of  the  femur 


336  APPARATUS  FOR  REMEDYING  LOSS  OF  SYMMETRY 

backward.  As  C and  D are  found  acting  above  and  below  the  actual 
axis  of  the  knee-joint,  they  mutually  influence  the  point  formed  by 
the  apposition  of  the  heads  of  the  tibia  and  femur ; and  as  it  has 
already  been  explained  that  the  femur  really  offers  a fixed  resistance, 


and  the  tibia  moves  beneath  it,  the  head  of  the  latter  bone  is  turned 
anteriorly  in  a semicircular  direction,  consequent  on  the  upper  centre 
(C)  being  a fixed  point,  and  the  lower  centre  (D)  rotating  around  it. 
G is  an  elastic  knee-cap;  H,  a padded  plate.  When  the  ligaments  are 
tense,  there  is  a chance  of  pressing  the  anterior  surface  of  the  tibia 
against  the  posterior  surface  of  the  femur.  This  is  readily  obviated 
by  having  the  shaft  (A)  made  to  elongate,  when  the  centre  (C).  being  a 
little  lowered,  pushes  the  lever  (B)  downwards,  carrying  the  tibia  with 
it,  and  thus  separating  the  osseous  surfaces  of  the  joint." 

Contraction  of  the  Hip-Joint. — Contraction  of  the  hip  consists 
in  the  thigh  being  bent  upon  the  abdomen.  In  the  greater  number 
of  cases  there  will  be,  besides  flexion,  more  or  less  adduction  of  the 
thigh,  by  which  the  knee  will  be  thrown  towards  or  even  across  the 
opposite  limb. 


Fig.  276, 


Fig.  277. 


Bigg’s  apparatus  for  contraction  of  the  kDee. 


OF  THE  LOWER  EXTREMITIES. 


337 


The  causes  of  this  condition  are  cerebral  or  spinal  irritation,  arthritic 
inflammation  of  the  hip,  violence  inflicted  upon  the  spine,  and  scrofu- 
lous disease  of  the  hip-joint. 

In  those  cases  originating  from  irritation  of  the  brain  or  spinal  cord, 
other  muscles  will  be  affected  along  with  the  flexors  and  adductors  of 
the  thigh ; there  will  generally  be  paralysis  of  the  extensors  of  the 
leg  and  flexors  of  the  foot,  so  that  the  muscles  opposing  them,  being 
no  longer  counteracted,  will  by  their  action  produce  more  or  less  con- 
traction of  the  knee  and  foot;  club-foot  is  also  commonly  associated 
with  contraction  originating  from  this  source. 

In  those  instances  again  which  spring  from  some  violence  impressed 
upon  the  line  of  the  spine,  paralysis  of  certain  muscles  will  be  induced, 
while  their  unopposed  antagonists  will  contract  and  maintain  the 
thighs  abnormally  bent  upon  the  pelvis ; here,  also,  the  legs  partici- 
pate to  a greater  or  less  extent  in  the  contraction. 

I have  recently  had  under  my  care  an  adult  in  whom  there  was 
contraction  of  both  thighs,  originating  from  gouty  inflammation  of  the 
coxo-femoral  articulations.  In  cases  of  this  description  no  paralysis 
will  be  found,  as  in  the  former  instance ; the  limbs  are  maintained  in 
that  position  in  which,  during  the  acute  stage  of  the  inflammation,  they 
have  been  instinctively  drawn  by  the  patient  for  the  purpose  of  alle- 
viating the  pain  in  the  joints;  the  muscles  insensibly  contract  and 
adapt  themselves  to  the  ne-w  condition  of  things. 

But  of  all  the  above-enumerated  cases  of  contraction  of  the  hip, 
scrofulous  disease  of  the  joint,  known  under  the  name  of  hip  disease,  or 
morbus  coxarius,  is  by  far  the  most  common.  It  begins  almost  always 
in  the  reticulated  structure  of  the  head  of  the  femur,  in  young  subjects 
between  the  ages  of  three  and  nine  years.  Cases  have  occurred 
inside  of  the  first  year,  and  as  late  as  adult  age,  but  they  are  rare. 
A case  occurred  in  my  practice,  in  which  the  patient  was  fifty-five 
years  of  age.  While  under  treatment,  which  consisted  in  the  applica- 
tion of  a modified  form  of  Davis’s  splint  during  the  day,  and  the  weight, 
cord,  and  pulley  at  night,  the  patient  improved  very  greatly,  so  much 
so,  indeed,  as  to  induce  him  to  quit  the  apparatus  several  weeks, 
during  which  time  he  took  active  exercise,  and  the  consequence  was 
that  he  was  again  brought  to  bed  with  acute  symptoms  of  local  inflam- 
mation of  the  hip-joint  that  ran  on  to  suppuration,  under  which  he 
ultimately  sank. 

This  disease,  like  other  scrofulous  affections,  is  slow  and  insidious 
in  its  approach,  being  scarcely  marked  in  the  early  period  of  its  course 
by  sufficiently  distinctive  characteristics  to  be  recognized,  except  by 
the  medical  attendant. 

In  the  first  stage  the  child  complains  of  weakness  and  weariness  in 
the  limb;  he  trips,  in  pursuing  his  accustomed  amusements,  with 
unusual  frequency,  and  complains  of  pain  in  the  knee  corresponding 
with  the  diseased  hip,  although  the  knee  does  not  present  any  evidence 
of  disease. 

In  a variable  period,  from  a few  weeks  to  as  many  months,  pain 
is  felt  in  the  hip  from  the  sensitive  nerves  of  the  bone  having  be- 
22 


338  APPAEATUS  FOR  REMEDYING  LOSS  OF  SYMMETRY 


come  involved,  the  limb,  perhaps,  loses  a little  flesh,  but  the  patient’s 
general  health  remains  unimpaired. 

In  the  second  stage  the  pain  in  the  hip  becomes  more  decided ; the 
health  of  the  patient  begins  to  fail,  his  digestive  functions  suffer,  his 
sleep  is  disturbed,  and  there  is  some  febrile  excitement  established. 
Along  with  the  general  wasting  of  flesh,  the  limb  becomes  attenuated 
and  the  gluteal  region  flattened;  the  gluteo-femoral  fold,  so  marked 
upon  the  healthy  side,  is,  upon  the  diseased  one,  completely  effaced. 

The  limb  is  apparently  elongated  from  the  tilting  of  the  pelvis 
toward  that  side ; the  loins  present  a hollow,  while  the  abdomen  is 
unusually  prominent ; the  upper  portion  of  the  thigh  becomes  swollen 
and  tender. 

In  the  third  stage  the  local  destruction  has  made  constant  progress; 
the  head  of  the  femur  and  portions  of  the  rim  of  the  acetabulum  are 
more  or  less  removed  b}r  ulcerative  action ; pus  has  formed  about  the 
parts,  and,  after  burrowing  in  every  direction,  finally  escapes  exteriorly, 
generally  in  the  gluteal  region  over  the  joint.  The  pain  is  severe, 
and  is  greatly  aggravated  by  impressing  movements  upon  the  limb, 
which  is  now  really  shorter  than  the  healthy  one  in  consequence  of 
the  ravages  in  the  head  of  the  femur  and  cotyloid  cavity.  The  hip, 
instead  of  being  flattened,  as  in  the  beginning,  is  now  prominent,  and 
the  thigh  is  more  or  less  bent  upon  the  pelvis,  and  generally  some- 
what adducted. 

The  severity  of  the  constitutional  symptoms  keeps  pace  with  that 
of  the  local  changes,  the  patient  suffering  from  severe  febrile  excite- 
ment and  copious  sweats. 

In  rare  instances  the  femur  becomes  dislocated  upon  the  dorsum  of 
the  ilium,  or  even  forwards  upon  the  pubis,  or  upon  the  thyroid  fora- 
men, or  backwards  into  the  ischiatic  notch. 

In  studying  the  phenomena  of  hip  disease  it  is  learned  that  it  is  of 
an  essentially  scrofulous  character.  The  ulcerative  changes  in  the  hip- 
joint  are  progressive,  destroying  successively  the  head  and  neck  of  the 
femur,  the  cotyloid  cavity,  the  cartilages,  synovial  membrane  and  liga- 
ments. Irritation  is  set  up  and  sustained  by  these  changes  so  that  the 
muscles  are  excited  to  energetic  contractions,  thereby  adding  still 
more  to  the  rapidity  of  the  ulcerative  destruction  by  pressing  the 
joint-surfaces  forcibly  together. 

Therefore,  in  fulfilling  the  indications  of  treatment  in  hip  disease,  it 
will  be  necessary,  first,  to  attend  to  the  correction  of  constitutional 
impairment  from  scrofulous  infection,  and  secondly,  to  separate  the  dis- 
eased bony  surfaces  by  appropriate  mechanical  contrivances.  The 
latter  point,  which  alone  concerns  us  here,  will  be  considered.  The 
necessity  of  making  extension  for  the  purpose  of  overcoming  the 
energy  of  the  irritated  muscles,  and  separating  the  diseased  joint-sur- 
faces has  been  long  recognized,  and  the  principle  carried  out  in  vari- 
ous ways,  usually  by  means  of  different  forms  of  couches,  to  which 
extending  bands  were  attached.  This  mode  of  treatment  had  the 
great  disadvantage  of  keeping  the  patient  in  a recumbent  position,  and 
depriving  him  of  the  benefits  of  pure  air,  change  of  scene,  and  all  those 
beneficial  influences  flowing  from  out-door  exercise. 


OF  THE  LOWER  EXTREMITIES. 


339 


To  Dr.  Henry  G.  Davis,  of  New  York,  is  due  the  credit  of  having 
first  systematized  the  use  of  practical  apparatus  which  admitted  of 
effectual  extension  being  made  without 
confining  the  patient  to  recumbency. 

The  apparatus  of  Dr.  Davis,  as  seen  in 
Fig.  278,  consists  of  a long  metallic  side- 
splint,  reaching  from  the  hip  to  the  ankle, 
consisting  of  two  sections,  which  are  mova- 
ble upon  each  other  by  means  of  a key. 

“To  the  upper  end  of  the  splint  a pero- 
neal band  is  attached,  formed  of  two 
bands  of  a length,  width,  and  strength 
varying  according  to  the  size  of  the  ap- 
paratus, and  the  circumstances  of  its 
application.  One  band  is  longer  than 
the  other,  and  inelastic,  being  made  en- 
tirely of  strong  cotton  or  linen  webbing; 
the  other  is,  as  it  were,  an  oblong  bag  of 
India-rubber  webbing  (formed  of  sewing- 
two  strips  of  rubber  webbing  together), 
filled  with  sawdust,  tipped  at  each  end 
with  some  of  the  inelastic  webbing. 

While  the  inside  elastic  band  keeps  up 
the  extension  required,  the  inelastic  sus- 
tains any  weight  that  exceeds  the  extend- 
ing force  as  then  applied  to  the  patient.  It  is  this  arrangement  that 
enables  the  weight  of  the  body  to  be  borne  without  harm,  as  in  walk- 
ing, and  that  prevents  injury  from  excessive  weight  or  pressure  upon 
the  articulating  surfaces  in  cases  of  accident.  Thus,  for  instance,  the 
head  of  the  femur  would,  in  walking,  be  violently  thrust  upwards,  as 
the  elastic  band  would  yield  to  an  increased  weight,  were  there  no  in- 
elastic, unyielding  band  to  prevent  it;  yet,  it  is  obvious  that  this 
inelastic  band  does  not  interfere  with  the  predetermined  amount  of 
tension  to  be  exerted  by  the  elastic  one.  (This  amount  of  extension 
is  determined  and  regulated  as  follows:  Buckle  the  two  bands  un- 
equally, i.  e.,  let  the  loop  formed  by  the  outside  band  be  longer  than 
that  of  the  inside,  and  attach  a weight  to  the  latter.  The  number  of 
pounds  requisite  to  stretch  the  one  loop  to  the  exact  length  of  the 
other  represents  the  amount  of  extending  force  the  instrument  will 
exert,  when  exactly  thus  buckled,  when  applied  upon  the  limb. 

“I  will  add,  that  here  the  amount  of  extending  force  should  be 
ascertained  in  every  instance  before  fastening  the  splint  upon  the 
patient;  this  amount  is  not  to  be  varied  by  altering,  by  means  of  the 
: saw,  the  length  of  the  instrument,  but  by  adjusting  the  two  bands.)” 
Dr.  Davis  says  that  the  long  splint  is  best  adapted  to  the  majority 
of  cases.  Some  years  ago  he  was  in  the  habit  of  applying  a shorter 
one,  seen  in  Fig.  279,  to  the  femur  alone.  This  leaves  the  knee  at 
liberty,  and  in  so  far  is  an  accommodation  to  the  patient,  but  other- 
wise is  not  so  effectual. 

In  applying  the  splint  “ cut  from  a piece  of  adhesive  plaster,  spread 


340  APPARATUS  FOR  REMEDYING  LOSS  OF  SYMMETRY 


Davis’s  short 
splint  for  coxal- 
gia. 


Fig.  281. 


on  twilled  goods,  and  kept  until  the  oil  entering  its 
composition  has  become  oxidized,  two  strips  from  one 
and  a quarter  to  one  and  a half  inches  wide,  of  the 
length  of  the  limb  from  the  pubis  to  the  malleolus,  and 
two  strips  a little  narrower  in  proportion  to  the  others, 
but  one  and  a half  times  as  long.  Fold  about  an  inch 
and  a half  of  one  extremity  of  each  of  the  first  cut 
strips  upon  itself,  the  adhesive  sides  to  each  other,  and 
apply  one  on  the  outside  and  one  on  the  inside  of  the 
limb,  commencing  with  the  folded  end  about  two  inches 
above  the  outer  and  inner  malleoli,  and  extending  it  up 
in  a straight  line. 

“ The  other  two  strips  are  applied  spirally  around  the 
limb  as  follows : Commence  on  the  lower  or  folded  ex- 
tremity of  the  straight  strip  above  the  outer  malleolus, 
and  wind  around  in  front  and  back,  so  that  the  two 
spiral  strips  meet  in  front,  a little  distance  above  the  patella.  Next, 
sew  a piece  of  firm,  inelastic  (linen  or  cotton)  webbing,  about  one  and  a 
quarter  inches  wide  and  six  to  eight  inches  long, 
to  the  lower  extremity  of  each  straight  strip,  tak- 
ing particular  care  to  include  in  the  attachment 
the  ends  of  both  spiral  strips  above  the  external 
malleolus.  The  limb  is  then  closely  and  firmly 
enveloped  with  a common  roller  bandage,  from 
the  foot  upwards,  the  pieces  of  webbing  only 
being  left  outside  free.  Now  buckle  the  ankle 
portion  of  the  splint  upon  the  external  face  of 
the  limb  by  means  of  the  webbing;  protect  the 
skin  of  the  groin  and  parts  to  be  covered  by  the 
perineal  band  by  a piece  of  old,  soft  napkin,  or 
table  linen,  several  times  folded  and  secured  by 
a few  stitches;  and  having  previously  adjusted 
the  two  bands  composing  the  perineal  band,  as 
already  mentioned,  fasten  the  latter  around  the 
thigh,  always  taking  care  to  have  the  buckle  on 
the  pelvic  portion  of  the  splint  in  front;  the 
screw  of  the  splint  regulates  its  length,  so  that 
the  required  amount  of  extension  can  be  secured. 
When  all  is  correctly  arranged,  and  proper  ex- 
tension made,  the  upper  extremity  of  the  splint 
should  fall  just  below  the  crest  of  the  ilium." 

Dr.  Lewis  A.  Sayre,  of  New  York,  has  modi- 
fied Dr.  Davis’s  splint ; he  adds  an  inside  splint, 
which  is  connected  with  the  external  one  by  a 
metallic  stem  arching  across  the  limb ; by  this 
means  extension  can  be  made  with  adhesive 
strips  applied  upon  both  sides  of  the  leg. 

Mr.  Richard  Harwell,  of  London,  has  also  carried  out  the  principle 
of  extension  in  the  treatment  of  coxalgia  by  the  ruder  splint  seen  in 


Fig.  282.  It  is  sufficiently  simple  to  be  extemporized  by  the  surgeon 


OF  THE  LOWER  EXTREMITIES. 


341 


without  the  aid  of  a mechanic,  and  it  will, 
therefore,  prove  of  service  where  the  more 
elegant  and  efficient  apparatus  of  Drs.  Davis 
and  Sayre  are  not  at  hand. 

Mr.  Barwell  says  that  “the  principle  of 
its  construction  is  to  make  a strong  India- 
rubber  spring,  or  accumulator,  act  as  both 
extending  and  counter-extending  force. 

For  this  purpose  it  is  fastened  by  each  end 
to  a piece  of  catgut  that  plays  round  pul- 
leys, attached  to  either  end  of  the  splint. 

“ The  splint  seen  in  the  figure,  though 
specially  arranged  for  the  hip,  with  suit- 
able modifications  may  very  easily  be  ap- 
plied to  any  joint. 

“A  long  Desault’s  splint  is  furnished  at 
its  upper  part  with  a wire  pelvic  belt  and 
a loop  of  strong  wire,  or  of  steel,  which 

I carries  a small  pulley,  and  which  projects 
outwards  about  an  inch  and  a half.  The 
lower  part  is  provided  with  a bar  running 
across  the  space  of  the  notch,  and  also  car- 
rying a pulley.  From  the  lower  end  of  the 
splint,  projecting  inwards  an  inch  or  an 
inch  and  a half,  is  another  loop,  carrying  a 
third  pulley.  A perineal  band,  passing  round  the  upper  part  of  the 
limb  and  splint,  has  a piece  of  rather  thin  catgut  (violin  string  A or  D) 
attached  to  it,  which  going  through  the  upper  loop  of  wire  runs  round 
the  pulley,  is  brought  down  on  the  outside  of  the  splint,  and  is  attached 
to  one  end  of  the  India-rubber  accumulator.  Round  the  foot  and  ankle 
are  fastened  two  pieces  of  webbing,  which  lace  over  the  instep,  and  to 
both  sides  of  which  is  sewn  tape,  forming  a loop  below  the  sole  of  the 
foot.  This  tape  affords  attachment  to  another  piece  of  catgut,  which 
plays  over  the  pulleys,  in  the  lower  part  of  the  splint,  and  is  tied  to 
the  other  end  of  the  accumulator  with  the  fitting  amount  of  tension.” 
Adhesive  strips  applied  to  the  leg  may  be  advantageously  substi- 
tuted for  the  webbing  in  making  extension. 

In  using  the  splint  “ the  surgeon  begins  by  applying  a broad  piece 
of  strapping  on  either  side  of  the  leg,  from  the  knee  to  the  foot,  allow- 
ing an  inch  or  an  inch  and  a half  of  the  material  to  project  below  the 
sole;  he  then  bandages  firmly  to  the  knee.  ...  It  is  better  to  leave  the 
patient  some  hours  before  any  force  is  exerted  on  the  strapping,  that 
it  may  establish  strong  adherence.  When  it  is  supposed  to  stick  suf- 
ficiently firm,  the  splint  is  to  be  placed  in  position ; the  upper  portion 
will  pass  round  the  pelvis,  the  lower  lie  along  the  bed,  quite  out  of 
reach  of  the  distorted  limb.  The  surgeon  now  bandages  from  the 
foot  to  the  top  of  the  thigh,  independent  of  the  splint;  arriving  at  the 
latter  place,  he  causes  the  bandage  to  pass  round  pelvis  and  thigh, 
including  all  the  upper  portion  of  the  splint,  thus  fixing  it  with  suffi- 
cient firmness.  Catgut  is  now  to  be  fastened  to  the  ends  of  the  plaster 


Fig.  282. 


342  APPARATUS  FOR  REMEDYING  LOSS  OF  SYMMETRY 

projecting  below  the  foot ; the  perineal  band,  properly  padded,  is  to 
be  adapted,  and  both  to  be  fastened  to  the  accumulator  with  the  proper 
degree  of  tension. 

“ For  the  first  ten  minutes  or  quarter  of  an  hour,  the  strain  should 
be  slight ; the  muscles  soon  after  its  application  set  up  a startled  sort 
of  resistance,  which,  however,  soon  subsides,  and  then  the  India-rubber 
is  to  be  pulled  tighter.  In  a few  hours  the  foot  or  knee  will  have 
descended  so  much  that  a nurse,  or  some  other  person  in  attendance, 
must  tighten  the  spring,  and  in  from  eighteen  to  thirty  hours  the  limb 
will  have  come  down,  and  may  be  bandaged  to  the  thigh  part  of  the 
splint.  This  will  have  been  effected  without  pain  or  violence ; indeed, 
the  starting  pains  previously  complained  of  will  even  abate  under  the 
downward  traction. 

“ If,  however,  the  malposture  be  more  fixed — that  is,  if  the  disease 
be  further  advanced  into  the  second  stage— the  thigh  cannot  be  thus 
drawn  down  without  producing  considerable  pain;  and  in  such  case 
it  will  be  better  to  give  chloroform,  and  while  the  patient  is  under  its 
influence  to  draw  down  the  limb  into  the  proper  position — namely, 
straight,  and  to  bandage  it  upon  the  splint.” 

Dr.  E.  Andrews,  of  Chicago,  has  constructed  an  apparatus  in  which 
extension  and  counter-extension  are  effected  by  an  inside  splint  made 
of  gas-pipe.  At  its  upper  end  a crutch-shaped  support  is  placed  work- 
ing into  the  stem  by  means  of  a screw,  to  rest 
against  the  perineum  aud  ischium  ; the  corners 
of  the  crutch  bear  straps  which  buckle  over  the 
hip ; the  lower  end  of  the  splint  is  connected 
with  the  sole  of  the  boot.  The  manner  in  which 
this  instrument  acts  is  sufficiently  clear : the 
limb  is  extended  by  means  of  the  screw,  so  that 
the  joint  surfaces  of  the  hip  are  separated ; while 
in  standing  the  weight  of  the  patient’s  body  is 
supported  upon  the  crutch  and  transmitted  to 
the  ground  by  the  side  splint. 

Dr.  Agnew,  of  Philadelphia,  has  also  sug- 
gested a modification  in  the  form  of  the  appa- 
ratus, so  that  the  perineal  strap  is  done  away 
with,  and  the  weight  of  the  body  is  sustained 
upon  the  perineum  and  ischium  by  the  upper 
edge  of  a padded  thigh-piece. 

The  contrivance,  as  seen  applied  in  Fig.  283, 
consists  of  an  outside  metallic  splint  extending  , 
from  a padded  pelvic  strap  to  the  margin  of  the 
sole  of  the  shoe ; it  can  be  lengthened  or  short- 
ened at  will,  so  that  an  appropriate  degree  of 
extension  may  be  obtained  upon  the  limb;  from 
the  obliquity  of  the  pelvic  strap  it  will  be  seen 
that  it  simply  adds  to  the  stability  of  the  appa- 
ratus without  assisting  in  any  degree  in  exerting 
counter-extension,  as  will  be  seen  in  the  instru- 
ment next  to  be  described.  There  is  also  an 


Fig.  283. 


Agnew’s  apparatus  for 
coxalgia. 


343 


OF  THE  LOW.EE  EXTKEHITIES. 

inside  splint,  constructed  exactly  ih\the  same  manner  as  the  former, 
reaching  from  the  inner  edge  of  the  shoe  sole  to  the  highest  point  of 
the  perineum.  The  two  splints  are  connected  above  by  a well-padded 
thigh-piece,  the  upper  margin  of  which  should 
reach  well  up  behind,  as  shown  by  the  dotted 
lines  in  the  figure,  to  press  against  the  ischium; 
a second  strap  encircles  the  leg  just  below  the 
knee. 

The  manner  of  fitting  the  thigh-piece  beneath 
the  buttock  is  seen  in  Fig.  284.  It  is  exactly  the 
same  plan  that  has  been  pursued  in  the  adapta- 
tion of  the  bucket  of  an  artificial  limb. 

Another  efficient  instrument  in  the  treatment 
of  coxalgia  will  be  found  in  the  one  of  which 
the  accompanying  wood-cuts  are  illustrations 
(Figs.  285  and  286). 

It  is  so  constructed  that  the  counter-extension 
or  counter-pressure  is  divided  between  the  elastic 
perineal  strap,  such  as  is  used  in  Davis’s  splint 
above  described,  and  a broad,  padded  pelvic 
strap ; the  latter  portion,  besides,  confers  greater 
firmness  and  stability  upon  the  apparatus.  The 

Fig.  285.  Fig.  286. 


Fig.  284. 


344  APPARATUS  FOR  REMEDYING  LOSS  OF  SYMMETRY 


outside  rod  extends  from  the  pelvic  belt,  to  which  it  is  attached  by  a 
ginglymoid  joint,  to  the  outer  margin  of  the  sole  of  a laced  boot.  This  ' 
rod  is  made  in  two  sections,  movable  upon  each  other,  so  that  it  can  be  j 
elongated  or  shortened.  An  inside  splint  stretches  from  a correspond- 
ing point  upon  the  internal  margin  of  the  sole  of  the  boot  to  the  mid-  : 
die  of  the  thigh.  The  two  rods  are  connected  together  by  two  well- 
padded  metallic  straps,  one  above  and  the  other  below  the  knee.  The 
elastic  perineal  band  is  connected  to  the  external  splint  by  means  of  a 
small  curved  metallic  stem,  articulated  with  it  in  the  same  manner  as 
in  Dr.  C.  F.  Taylor’s  modification  of  Davis’s  splint. 

The  mode  in  which  this  apparatus  is  applied  is  seen  in  Fig.  286. 

It  is  necessary,  in  overcoming  the  contraction  of  the  muscles,  that 
the  extension  should  be  continual,  and  therefore,  when  the  splint  is 
not  upon  the  patient’s  person,  a weight,  passing  over  a pulley  at  the 
foot  of  the  bed,  should  be  hooked  to  the  extending  band. 

In  the  early  stage  of  coxalgia,  when  there  is  no  abnormal  contrac- 
tion of  the  muscles  nor  deformity  of  the  limb,  the  application  of  the 
wire  splint,  seen  in  the  annexed  drawing  (Fig. 

287),  will  be  found  advantageous.  It  incloses  Fis-  288. 

the  diseased  hip  and  the  corresponding  thigh 
and  leg,  securing  perfect  immobility  of  those 
parts  without  interfering  with  the  movements 
of  the  rest  of  the  body,  which  is  an  advantage 
of  no  small  importance  in  relieving  the  patient 
of  much  of  the  physical  restraint  and  injurious 
influences  of  a protracted  recumbency  imposed 

Fig.  287. 


Wire  splint  for  coxalgia.  Mode  of  applying  the  wire  splint. 


by  some  of  the  couches  and  apparatus  sometimes  employed  in  the 
treatment  of  this  disease,  while  at  the  same  time  it  secures  all  the 


OF  THE  LOWER  EXTREMITIES. 


345 


good  that  can  be  conferred  by  them.  The  manner  in  which  this  splint 
is  applied  is  very  well  shown  in  Fig.  288. 

When  the  wire  splint  is  not  attainable,  a less  elegant,  but  yet  no 
!'  less  efficient  splint,  may  be  prepared  with  plaster  of  Paris  in  the  man- 
ner described  under  the  section  treating  of  fractures  ; and  in  several 
cases  in  which  I have  employed  it,  entire  satisfaction  was  obtained. 
Gutta-percha  and  pasteboard  may  also  be  used  for  making  the  splint. 


PART  III. 


FRACTURES:  THEIR  REDUCTION,  DRESSINGS,  AND 
APPARATUS. 


CHAPTER  I. 

GENERAL  CONSIDERATION  OF  FRACTURES. 

Fracture  may  be  defined  to  be  a solution  of  continuity  of  a bone 
resulting  from  external  violence  or  muscular  action. 

Up  to  the  age  of  twenty-one,  and  even  later,  before  ossification  has 
been  completed,  the  epiphyses  may  be  separated  from  the  shafts  of 
the  long  bones,  constituting  what  is  called  a “ diastasis,”  which  re- 
sembles fracture  so  closely  in  its  causes  and  symptoms  that  it  would 
be  doing  considerable  violence  to  pathological  analogy  to  consider 
the  two  injuries  separately. 

Classification. — When  a bone  is  broken  into  two  pieces,  the 
fracture  is  said  to  be  simple;  when  into  more  than  two  pieces,  mul- 
tiple or  comminuted.  A broken  bone,  communicating  exteriorly 
through  a wound,  constitutes  a compound  fracture  ; a complicated  frac- 
ture is  accompanied  with  a dislocation,  rupture  of  bloodvessels  or 
nerves — or,  indeed,  with  any  other  unusual  and  severe  injury. 

The  terms  complete  and  incomplete  refer  to  the  fact  of  the  fracture 
running  either  completely  or  partially  through  the  bone. 

The  line  of  fracture  may  pass  through  the  bone  parallel  with  its 
axis,  at  right  angles  to  it,  or  in  a direction  between  these  two;  this 
establishes  a further  division  of  these  injuries  into  longitudinal,  trans- 
verse, and  oblique  fractures.  There  are  a few  recorded  examples  of 
perfect  longitudinal  fractures,  and  they  are  generally  the  result  of  a 
gunshot.  In  other  instances  they  are  always  accompanied  with  one 
of  the  other  varieties. 

In  old  persons,  and  those  with  very  brittle  bones,  a transverse  frac- 
ture may  be  encountered,  though  it  will  generally  be  accompanied 
with  some  little  obliquity,  yet  not  sufficient  to  permit  the  ends  of  the 
bone  slipping  beyond  each  other  aud  overlapping. 

Thus  it  appeal’s  that  oblique  fractures  are,  by  all  odds,  the  most 
common,  and  are  those  always  observed  in  healthy  aud  vigorous 
persons. 

Occasionally  it  happens  that  one  extremity  of  a fragment  has  inden- 
tations upon  it  which  receive  corresponding  elevations  upon  the  face 
of  the  other,  forming  what  has  been  called  a serrated  fracture. 


CAUSES  OF  FRACTURE. 


347 


the  other  and  remaining  fixed. 

Malgaigne  has  proposed  the  introduction  of  the  terms  single  and 
multiple  to  express  the  number  of  pieces  into  which  a bone  is  broken. 

Frequency. — The  bones  are  not  all  equally  liable  to  fracture ; the 
clavicle  suffers  more  frequently  than  any  other  in  the  proportion, 
according  to  the  statistics  of  Malgaigne,  of  360  in  900  of  all  kinds. 
The  long  bones  of  the  extremities,  particularly  the  upper,  from  their 
extended  range  of  motion  and  great  length  of  leverage  presented  to 
the  action  of  external  and  muscular  forces,  are  necessarily  much  more 
often  broken  than  the  short  bones,  which  are  at  once  limited  in 
extent  of  movement,  and  more  compactly  bound  together  by  short 
and  strong  ligamentous  bands,  and  they  are  therefore  less  liable  to 
suffer  damage  to.  their  continuity  by  mechanical  agencies. 

Causes. — The  causes  of  fracture  may  be  conveniently  divided  into 
the  predisposing  and  exciting;  among  the  former  class  we  find  those 
diseases  which  sap  the  strength  and  constitutional  forces,  producing 
alterations  in  the  organic  integrity  of  the  bones  themselves — such  as 
scrofula,  gout,  scurvy,  rheumatism,  syphilis,  mollities  and  fragilitas 
ossium,  and  cancer.  Old  age,  from  the  changes  in  the  relative  pro- 
portion of  earthy  and  animal  constituents  of  bone  which  accompanies 
it,  is  also  a strong  predisposing  cause.  Sex  also  has  a certain  influ- 
ence, inasmuch  as  males  meet  with  the  accident  more  frequently  than 
females  in  the  proportion  of  7 to  5;  a difference,  probably,  depending 
upon  the  greater  exposure  of  the  former  class  of  persons  to  the  exciting 
causes  of  fracture  in  the  pursuit  of  their  peculiar  avocations.  On  the 
other  hand,  aged  females  more  frequently  suffer  from  this  accident 
than  the  corresponding  class  of  males. 

The  exciting  causes  of  fracture  are  two,  namely,  external  violence 
and  muscular  action.  External  violence  varies  in  intensity  from  a 
force  just  sufficient  to  break  the  bone  to  that  excessive  degree  whereby 
the  bones  and  soft  parts  are  crushed  and  mangled  frightfully,  as  is 
exemplified  in  railroad  accidents  and  gunshot  wounds. 

When  the  bone  gives  way  at  the  point  where  the  violence  is  ap- 
plied, the  fracture  is  said  to  occur  from  direct  force ; and  from  contre- 
coup,  or  counter-stroke,  when  it  takes  place  some  distance  from  this 
point,  as  occurs  sometimes  when  a person  falls  from  a height  upon 
his  feet,  breaking  the  bones  of  the  leg. 

A fracture  may  occur  at  any  point  in  the  continuity  of  the  long 
bone,  but  most  frequently  it  takes  place  in  the  middle  third  of  its 
diaphysis;  and  more  especially  does  it  do  so  when  the  injury  results 
from  counter-stroke.  The  reason  of  this  will  be  found  in  the  fact  that 
this  section  of  the  bone  offers  less  resistance  to  the  force  than  any 
other.  There  are  other  circumstances  determining  the  point  of 
breakage,  such  as  the  direction  of  the  force,  the  position  of  the  limb  at 
the  time  of  the  injury,  the  connection  of  the  bones  with  the  adjacent 
parts;  and  lastly,  the  manner  in  which  the  force  is  decompounded 
’and  transmitted  by  the  bones.  In  illustration  of  the  last  point,  it  may 
be  mentioned  that  in  those  sections  of  the  limbs  possessed  of  two 
bones,  the  application  of  violence  may  fracture  the  latter  at  different 


348  GENERAL  CONSIDERATION  OF  FRACTURES. 

points,  the  larger  bone  below,  and  the  smaller  one  at  some  point 
above.  This  fact  is  explicable  when  it  is  considered  that  in  the  arm 
and  leg  the  radius  and  tibia  form  the  larger  portions  of  the  wrist  and 
ankle-joints ; hence  in  falls  upon  the  palms  of  the  hand  and  soles  of 
the  feet,  they  receive  and  transmit  a greater  share  of  the  force; 
from  their  size  not  being  able  to  yield  sufficiently  rapid  to  the  violence 
from  below,  this  accumulates  at  a given  point  above  the  ankle  and 
wrist,  and  a fracture  ensues ; the  ulna  and  fibula,  on  the  other  hand, 
receiving  and  transmitting  a less  amount  of  force  from  their  slighter 
connections  with  the  joints,  and  yielding  more  rapidly  than  the  large 
bones,  do  not  give  it  a chance  to  accumulate  sufficiently  to  damage 
them  until  it  reaches  a higher  point,  where  the  break  will  occur. 

Violent  muscular  action  less  frequently  determines  fracture  than 
external  violence,  and  it  is  principally  observed  in  the  olecranon, 
patella,  and  os  calcis.  Malgaigne  denied  that  muscular  action  alone 
was  ever  an  efficient  cause,  in  the  long  bones,  without  previous  disease 
of  their  structure;  but  the  recorded  cases  of  such  injuries  prove  irre- 
fragably  that  this  has  occurred,  not  only  in  the  humerus,  maxilla, 
radius,  ulna,  and  bones  of  the  leg,  but  even  in  the  femur — the  largest 
and  strongest  long  bone  of  the  skeleton— without  any  precedent 
disease  whatever.  Though  it  can  scarcely  be  doubted  that  in  a 
majority  of  such  cases  the  broken  bones  will  be  found  to  have  under- 
gone more  or  less  morbid  change  of  structure,  so  as  to  become  brittle; 
this  fact  will  also  explain  why  it  is  that  most  of  the  fractures  from 
muscular  force  approximate  more  or  less  to  a transverse  direction. 

Some  of  the  congenital  cases  of  fracture  have  been  attributed  to  the 
violent  contractions  of  the  uterus  during  parturition. 

Symptoms.— It  is  very  important  that  the  practitioner  should  study 
accurately  the  symptoms  which  announce  and  accompany  fracture, 
for  upon  such  knowledge  the  correct  diagnosis  of  the  case  will  depend; 
they  are  crepitus,  preternatural  mobility,  deformity,  deprivation  of 
natural  function,  contusion,  pain,  and  some  constitutional  disturbance. 

Crepitus. — This  is  the  peculiar  sound  produced  by  the  rubbing 
together  of  the  opposing  fractured  ends  of  a bone ; it  will  be  most 
evident  in  those  cases  where  the  fragments  are  not  displaced,  and  are 
surrounded  by  a slight  thickness  of  soft  parts.  Should  the  ends  be 
impacted  or  overlapped,  crepitus  will  not  be  heard  at  all,  though  in 
the  latter  case  it  may  be  developed  by  extending  the  limb.  The  mode 
of  eliciting  this  sound,  commonly  adopted  by  the  surgeon,  is  to  seize 
the  fragments  in  both  hands  and  move  them  in  opposite  directions ; in 
the  thigh,  the  surgeon  sometimes  directs  an  assistant  to  rotate  the  limb, 
while  he  brings  his  ear  near  the  seat  of  injury.  These  measures,  as 
indeed  in  all  other  manipulations  in  fractures,  should  be  accomplished 
with  the  greatest  gentleness.  Though  crepitus  may  generally  be  both 
heard  and  felt,  yet  there  are  cases  in  which  the  surgeon  is  compelled 
to  depend  upon  the  latter  sense  alone;  the  impression  communicated 
to  the  touch  by  crepitus  may  be  obscure,  yet  with  a little  practice  it 
may  be  discriminated  from  that  produced  by  the  rubbing  together  of 
cartilages  or  surfaces  roughened  by  deposited  lymph. 

Preternatural  Mobility. — This  is  observed  when  a bone  is  broken 


SYMPTOMS. 


349 


clear  through,  and  its  ends  not  entangled  with  each  other ; if  the  limb 
is  raised,  that  portion  of  it  below  the  fracture  may  be  moved  freely  in 
every  direction.  It  will  be  evident,  more  or  less,  from  the  beginning 
of  the  injury  to  the  time  when  consolidation  of  the  fragments  is  about 
occurring.  Preternatural  mobility  may  also  be  present  in  dislocation 
in  which  there  is  extensive  laceration  of  the  ligaments,  but  may  be 
[distinguished  from  that  of  fracture  by  the  characteristic  symptoms  of 
dislocation  which  accompany  it. 

Deformity  manifests  itself  in  several  modes  ; when  there  is  an  over- 
riding of  the  fragments  the  limb  will  be  shortened  to  an  extent  varying 
from  one  inch  to  three  and  a half  inches,  the  average,  perhaps,  being 
[about  an  inch.  In  impacted  and  partial  fractures,  particularly  the 
latter,  shortening  may  not  be  at  all  apparent ; we  may  also  mention 
[those  cases  in  which  the  line  of  breakage  is  so  nearly  transverse  that 
the  ends  of  the  bone  remain  in  contact.  The  shortening  in  fracture 
[can  almost  certainly  be  diagnosticated  from  that  encountered  in  dislo- 
cation by  the  fact  that  in  the  former  case  moderate  extension  causes 
the  deformity  to  disappear,  and  as  soon  as  the  force  is  withdrawn  the 
(shortening  recurs ; exactly  the  reverse  is  generally  true  in  dislocation. 
[The  causes  of  shortening  are,  first,  the  violence  which  produced  the 
injury  driving  the  ends  of  the  pieces  of  bone  past  each  other; 
[secondly,  muscular  contraction,  wdiich  brings  about  the  same  result 
more  constantly,  and  against  which  art  has  most  to  struggle  in 
[opposing  deformity,  while  the  patient  progresses  to  convalescence. 

The  limb  may  also  be  curved  or  angular  at  the  point  of  fracture 
by  the  lateral  displacement  of  the  fragments,  and  indeed  there  may 
be  actually  a doubling  of  the  limb  upon  itself,  as  I saw  in  several 
"cases  during  the  rapid  transportation  of  the  wounded  after  a disas- 
trous repulse  in  attacking  a fort. 

Another  form  of  deformity  results  from  the  rotation  of  the  lower 
fragment  of  a broken  bone  upon  its  axis,  which  is  so  frequently  seen 
in  fractures  of  the  femur  in  consequence  of  the  weight  of  the  limb 
below  the  point  of  injury. 

Deformity  may  occur  immediately  upon  the  infliction  of  the  vio- 
lence or  after  the  lapse  of  several  days. 

Deprivation  of  Natural  Function. — It  may  be  readily  conceived  that 
a patient  with  a fractured  limb  may  not  be  able  to  raise  it,  or  to  sup- 
port the  weight  of  the  body  upon  it,  since  the  bones  cease  to  furnish 
that  powerful  leverage  indispensable  to  the  muscles  in  the  exercise  of 
their  functions;  besides,  the  muscles  are  generally  so  much  bruised 
and  sore  that  a patient  cannot  often  summon  the  required  amount  of 
murage  to  make  such  efforts.  This  loss  of  function,  though  a striking 
feature  of  fracture,  is  yet  not  invariably  present ; the  fragments  may 
be  impacted  when  the  injury  occurs  in  the  neck  of  the  femur,  or  only 
)ne  of  the  two  bones  composing  the  leg  may  be  broken,  in  which 
nstances  a person  may  be  able  to  walk  some  distance,  and  it  is  even 
stated  that  when  both  the  tibia  and  fibula  are  broken  progression 
nay  not  be  impossible.  In  the  case  of  fractured  clavicle  a person 
han  perform  the  movements  of  circumduction  and  place  the  hand 
ipon  the  top  of  his  head. 


350 


GENERAL  CONSIDERATION  OF  FRACTURES. 


Contusion. — In  all  cases  of  fracture  there  is  more  or  less  contusion  of 
the  soft  parts,  producing  rupture  of  the  bloodvessels,  and  subsequent 
effusion  of  blood,  followed  by  inflammation,  swelling,  and  effusion  of 
serum.  These  concomitants  sometimes  render  the  diagnosis  difficult, 
if  not  impossible,  by  preventing  the  Angers  of  the  surgeon  coming  in 
sufficiently  close  proximity  with  the  bone  to  ascertain  its  condition. 

Pain. — This  symptom  is  rarely  absent  in  any  case  of  fracture,  and 
is  commonly  felt  at  the  seat  of  the  injury;  it  is  aggravated  by  pressure 
or  the  slightest  movement  of  the  limb,  and  in  nervous  subjects  is  not 
unfrequently  accompanied  with  spasmodic  action,  which  entails  often 
the  most  horrible  suffering  upon  the  patients.  The  cause  of  pain  is 
the  tearing  or  bruising  of  the  soft  parts,  and  consequent  laceration  of 
their  nervous  filaments  by  the  broken  ends  of  the  bone.  From  the 
concussion  of  the  nerves  a numbness  is  produced  at  the  seat  of  the 
injury,  and  in  some  cases  the  whole  limb  may  suffer  in  the  same 
manner,  or  a patient  may  complain  of  numbness  over  the  entire  body, 
either  at  the  time  of  injury,  or  after  the  lapse  of  several  days. 

Constitutional  Disturbance. — The  constitutional  disturbance  following 
fracture  varies  with  the  violence  of  the  injury  and  the  extent  of  damage 
done  the  body,  from  a scarcely  noticeable  febrile  movement  to  great 
nervous  perturbation  and  excessive  febrile  reaction. 

Diagnosis. — Fractures  have  been  confounded  with  sprains,  disloca- 
tions, several  diseases  of  the  joints,  necrosis,  and  caries.  Should  the 
injury  be  located  near  the  diaphysis  of  a bone,  the  diagnosis  will 
generally  be  easy;  while,  on  the  other  hand,  when  it  is  near  the  joints, 
there  is  often  great  difficulty  encountered ; it  is  in  such  cases  that 
the  greatest  experience  and  skill  are  necessary  to  rightly  elucidate 
the  nature  of  the  injury.  In  all  cases  the  practitioner  will  require  a 
thorough  knowledge  of  the  above  detailed  symptoms,  which,  taken  in 
connection  with  other  circumstances,  such  as  the  history  of  the  case, 
age  of  the  patient,  mode  in  which  the  injury  was  inflicted,  &c.,  will 
enable  him  to  come  to  a correct  decision. 

Prognosis.— The  surgeon  should  be  governed  in  his  prognosis  of 
a case  of  fracture  by  the  knowledge  he  has  of  the  amount  of  injury 
inflicted  upon  the  soft  parts ; whether  the  fracture  is  simple  or  com- 
pound, or  complicated  with  rupture  of  bloodvessels,  of  nerves,  or  of 
tendons;  any  of  these  conditions  rendering  the  case  much  more  serious. 
A partial  or  an  impacted  fracture  is  more  favorable  for  the  ultimate 
restoration  of  the  function  of  a limb  than  the  other  varieties;  so  a 
transverse  fracture  will  heal  with  less  deformity  than  an  oblique  one. 
The  prognosis  will  be  more  grave  the  nearer  the  injury  is  to  the 
larger  joints;  fractures  of  the  upper  extremities  unite  more  quickly 
than  those  of  the  lower.  Young  and  healthy  persons  recover  more 
frequently  and  rapidly  than  those  broken  down  by  disease,  intem- 
perance, and  age. 

Mode  of  Repair  of  Fractures. — The  recuperative  efforts  of  na- 
ture proceed  in  the  repair  of  broken  bones  in  the  same  manner  as 
they  do  in  that  of  the  soft  tissues,  modified  of  course  to  some  extent 
by  the  peculiarity  of  their  composition  in  containing  such  an  abun- 


MODE  OP  REPAIR  OF  FRACTURES. 


351 


dance  of  the  calcareous  salts.  There  may  be  an  effusion  of  plastic 
matter  around  the  ends  of  the  bone,  which  is  subsequently  converted 
into  bone,  or  the  consolidation  may  occur  by  a process  analogous  to 
that  of  immediate  union.  The  mode  pursued  will,  in  a considerable 
degree,  depend  upon  the  relations  of  the  ends  of  the  broken  bone  to  each 
other,  their  mobility,  the  extent  of  the  complications  of  the  injury,  and 
whether  the  injured  bone  is  shut  in  from  the  air  or  not.  According  to 
the  investigations  of  Mr.  Paget,  of  London,  the  old  views  of  Dupuytren, 
that  a provisional  and  definitive  callus  were  necessary  and  always 
present  in  the  course  of  the  healing,  are  no  longer  tenable.  In  a few 
exceptional  cases  no  callus  is  formed,  nor  even  lymph  thrown  out, 
but  the  bone  appears  to  unite  immediately  by  the  re-establishment  of 
the  continuity  of  the  bony  fibres  and  bloodvessels.  The  reparative 
process  does  not  begin  before  the  eighth  or  twelfth  day  after  the  in- 
jury;  during  this  period  of  apparent  rest  the  inflammation  diminishes, 
any  effused  blood  which  may  have  been  poured  out  among  the  tissues, 
and  which  rarely  takes  any  share  in  the  healing,  is  gradually  absorbed, 
and  along  with  it,  in  the  most  favorable  cases,  the  inflammatory  lymph 
also  disappears.  At  the  expiration  of  the  above  stated  time,  when 
these  fluids  have  been  more  or  less  cleared  away  from  the  neighbor- 
hood of  the  fracture,  the  proper  reparative  materials  are  extravasated, 
by  the  organization  of  which  the  reunion  of  fractures  is  commonly 
effected.  This  plastic  matter  does  not  appear  to  differ  from  the  ma- 
terial furnished  for  the  healing  of  the  tendons  subcutaneously.  It  is 
a “structureless  or  dimly-shaded  granular  substance,  like  fibrin;  or 
perhaps,  at  a later  period,  it  is  ruddy,  elastic,  moderately  firm,  and 
succulent,  like  firm  granulation  substance.”  This  matter  is  placed  in 
various  positions  as  regards  the  broken  ends  of  a bone,  but  two  prin- 
cipal modes  have  been  observed : first,  it  incloses  them  like  a ferule, 
and  is  then  called  the  provisional  or  external  callus,  and  by  Mr.  Paget 
'the  ensheathing  callus ; secondly,  the  matter  is  laid  between  the  sur- 
faces of  the  bone  in  contact  with  each  other,  or  in  the  angle  formed  by 
ane  fragment  overhanging  the  other,  when  it  is  named  the  intermediate 
callus.  The  former  plan  is  rarely  observed  in  the  human  subject, 
except  in  those  bones,  such  as  the  ribs,  which  must  necessarily  be  in 
continual  motion,  and  also  in  children,  in  whom  it  is  difficult  to  keep 
ihe  limbs  quiet  during  the  period  of  ossification  of  the  broken  bone ; 
while  it  is  the  common  mode  of  repair  in  animals.  The  callus  usually 
extends  about  a half  inch  above  and  below  the  plane  of  fracture,  and 
oresents  a constricted  appearance  about  its  middle.  It  commonly  lies 
cetween  the  bone  and  periosteum,  raising  that  membrane  from  contact 
with  the  surface  beneath. 

The  interior  callus  fills  up  the  cells  of  the  medullary  canal,  extend- 
ng  above  and  below  the  plane  of  fracture  a distance  somewhat  short 
>f  that  of  the  external  callus.  When  the  callus  is  well  formed,  the 
cone  may  be  restored  to  its  former  usefulness,  although  its  walls  yet 
Remain  ununited,  which  requires  a lengthy  period,  perhaps  as  much 
p eight  months  in  a long  bone ; and  not  until  the  expiration  of  this 
ime  are  the  materials,  that  have  gone  to  form  the  callus,  absorbed, 
eaving  the  surface  of  the  bone  smooth  and  uniform. 


352 


GENERAL  CONSIDERATION  OF  FRACTURES. 


The  second  plan  of  union,  or  that  by  an  intermediary  callus,  is  the 
one  commonly  observed  in  man ; the  reason  of  this  is  to  be  found  in 
the  fact  that  the  fractured  limbs  of  persons,  with  the  exception  noted 
above,  are  kept  in  greater  quietness  during  their  care  than  can  be 
obtained  in  inferior  animals.  An  additional  reason  is,  that  man  pos- 
sesses a much  less  disposition  to  ossific  formation  than  animals. 
The  reparative  matter  is  not  only  deposited  between  bony  surfaces  in 
contact,  but  it  may  extend  also  between  those  separated  by  a con- 
siderable interval. 

The  process  of  ossification  may  take  place  in  one  of  three  manners. 
That  commonly  observed  in  adult  long  bones,  in  favorable  cases,  is 
by  means  of  a nucleated  blastema,  a sort  of  rudimental  fibrous  tissue. 
In  compound  fracture  the  new  bone  may  be  formed  by  ossification  of 
the  nucleated  cells  of  the  granulations.  In  other  instances  the  repa- 
rative materials  may  pass  through  an  intermediate  state  either  of  car- 
tilage or  of  fibrous  tissue;  the  former  plan  being  sometimes  observed 
in  children,  but  rarely  in  adults;  and  it  appears  to  be  the  common 
mode  of  ossification  in  animals. 

In  whatever  manner  ossification  may  take  place,  by  a subsequent 
process  of  absorption  the  injured  bone  is  modelled,  as  it  were,  into  its 
normal  shape;  its  exterior  surface  is  bevelled  and  smoothed,  while 
the  cells  of  the  cancellated  structure  are  cleared  of  the  interior  callus, 
until  they  form  the  natural  and  continuous  medullary  structure  of 
healthy  bone,  shut  in  by  the  new  walls  of  compact  tissue. 

The  periods  occupied  by  these  several  parts  of  the  reparative  pro- 
cess have  not,  as  yet,  been  accurately  determined,  but  the  following 
may  be  regarded  as  approximations  to  the  truth:  Eight  or  ten  days 
elapse  before  the  proper  materials  are  poured  out;  from  that  time  to 
about  the  twentieth  day  these  become  converted  into  a fibrous  or  car- 
tilaginous condition,  when  bone  begins  to  appear,  and  continues  to  he 
deposited  until  ossification  is  complete,  which,  though  exceedingly 
variable  as  to  time,  is  rarely  less  than  sixty  or  seventy  days. 

Ununited  Fractures. — From  constitutional  or  local  causes  the 
process  of  repair  may  fail,  and  the  fragments  of  bone  will  not  he 
united  at  all,  or  perhaps  by  a fibrous  or  fibro-cartilaginous  tissue, 
forming  what  has  been  called  a pseudarthrosis,  or  false  joint.  The  ends 
of  the  bone  will  generally  be  found  rounded  offi  and  covered  with  a 
layer  of  dense  fibrous  tissue,  or  a cartilaginous  incrustation,  consti- 
tuting a structure  somewhat  analogous  to  a joint ; sometimes  there  is 
a bursal  sac  developed  between  the  bones.  In  other  cases,  instead  of 
a false  joint  being  formed,  the  whole  of  the  diaphysis  of  the  bone  may 
be  absorbed. 

Treatment  of  Ununited  Fracture. — In  this  place  the  apparatus  only 
which  have  been  found  useful  in  the  treatment  of  false  joint  will  detain 
us,  inasmuch  as  the  various  surgical  procedures  of  seton,  cauterization, 
acupuncture  and  resection,  are  more  properly  treated  of  in  general 
works  on  surgery. 

The  common  object  of  all  bandages  or  apparatus,  in  these  cases,  is 
to  make  pressure  upon  the  broken  extremities  of  the  bone,  and  to  sup- 
port the  limb  rigidly,  so  as  to  cause  a sufficient  amount  of  irritation 


MODE  OF  REPAIR  OF  FRACTURES. 


353 


about  them  as  to  lead  to  an  ossific  deposition  in  the  false  joint.  The 
compression  may  be  effected  by  some  of  the  apparatus  to  be  de- 
scribed further  on;  the  main  point  to  be  attended  to  is,  that  the 
pressure  shall  be  firm,  continuous,  and  uniform. 

For  ununited  fracture  of  the  lower  extremities,  Prof.  Henry 
Smith,  of  this  city,  has  recommended  the  apparatus  seen  in  Fig.  289. 
It  consists  of  two  metallic ' side  rods,  the  outer  one  extending 
from  the  shoe  to  the  hip,  and  the  inner  one  reaching  to  the  peri- 
neum, connected  together  by  long  thigh-splints,  straps  and  buckles. 
The  rods  are  provided  with  joints  at  the  hip,  knee,  and  ankle;  a 


Fig.  289. 


Fig.  290. 


pelvic  strap  is  connected  with  the  upper  extremity  of  the  outer  rod. 
When  the  apparatus  is  applied,  the  patient  is  enabled  to  take  out-door 
exercise,  which  will  materially  contribute  to  a successful  issue.  Of 
, similar  construction  is  Dr.  Smith’s  apparatus  for  ununited  fracture  of 
the  leg  (Fig.  290).  It  possesses  the  same  advantages  as  the  previous 
instrument  in  sustaining  the  fragments  of  the  bone  immovable,  while 
the  patient  bears  his  weight  upon  the  limb,  and  moves  around  in  the 
open  air. 

Both  of  these  are  elegant  contrivances,  and  of  real  utility  in  the 
-reatment  of  ununited  fracture;  they  deserve  a continuous  and  faithful 
-rial  before  any  severe  surgical  procedure  shall  be  had  recourse  to 
;o  effect  the  consolidation  of  the  fracture. 

In  absorption  of  the  diaphysis  of  the  bone,  an  apparatus  taking  its 
searings  above  and  below  the  point  of  fracture,  by  means  of  two  cir- 
23 


354 


GENERAL  CONSIDERATION  OF  FRACTURES. 


cular  and  well-padded  metallic  straps  connected  laterally  by  two  side- 
rods,  may  be  employed  witb  advantage;  in  the  arm,  for  instance,  the 
upper  strap  may  be  applied  below  the  shoulder,  and  the  lower  one 
just  above  the  elbow,  while  the  side-rods  will  retain  them  sufficiently 
far  apart,  and  at  the  same  time  give  enough  rigidity  to  the  limb  to 
enable  the  extensor  and  flexor  muscles  to  act  to  an  advantage. 

Sometimes,  from  bad  treatment  or  other  causes,  the  pieces  of  bone 
may  unite  at  an  angle,  or  in  such  a manner  that  deformity  will  follow. 
In  this  case  the  judicious  use  of  mechanical  contrivances  will  accom- 
plish a great  deal  in  restoring  the  limb  to  its  proper  shape  and  useful- 
ness. An  appropriate  instrument  in  such  instances  has  already  been 
described  in  Part  II.  The  principle  involved  in  its  use  is  to  bring 
direct  pressure  upon  the  top  of  the  arch  formed  by  the  crooked  line, 
while  its  extremities  serve  as  points  of  counter-pressure. 

Compound  Fractures. — In  our  previous  observations  we  have 
principally  alluded  to  simple  fractures,  and  it  will  not,  therefore,  be 
inappropriate  to  introduce  a few  remarks  here  concerning  those  which 
are  compound  and  complicated.  Fortunately,  this  class  of  injuries 
forms  a very  small  proportion  of  those  fractures  the  surgeon  is  called 
upon  to  treat ; they  are  most  commonly  observed  in  the  leg  and 
thigh,  and  are  often  attended  with  violent  inflammation  and  suppura- 
tion, demanding  total  abstinence  from  the  application  of  apparatus  in 
the  beginning  of  the  treatment;  the  limb  being  simply  placed  in  the 
most  comfortable  and  advantageous  position  upon  pillows  and 
cushions  to  facilitate  the  application  of  the  dressing  and  the  cleansing 
of  the  wound.  The  reduction  should  always  be  accomplished,  if  it  is 
practicable,  immediately  after  the  injury;  if  the  bone  protrudes  from 
the  wound,  an  effort  should  be  made  to  restore  it  to  its  natural  posi- 
tion by  making  gentle  extension;  while  the  surgeon  may  facilitate  the 
operation  by  stretching  the  orifice  with  his  fingers,  or  a wooden  spa- 
tula. When  these  efforts  fail,  then  nothing  remains  but  to  enlarge  the 
wound  a little  with  the  scalpel ; or,  better,  to  saw  off  the  projecting  bone. 

Once  the  reduction  is  accomplished  the  wound  must  be  brought 
together  so  as  to  exclude  the  air  if  possible,  and  place  the  injury  un- 
der the  conditions  of  a simple  fracture.  If  the  case  does  not  do  well, 
and  pus  forms,  the  wound  must  be  again  opened  to  permit  the  matter 
to  have  a free  escape  externally. 

To  make  gentle  compression  upon  the  parts  the  most  elegant  and 
convenient  bandage  is  that  of  Scultetus ; warm  or  cold  water-dress- 
ings may  then  be  applied  according  to  the  feelings  of  the  patient. 
My  experience  during  the  war  with  bad  compound  fractures  led  me 
to  abandon  almost  entirely  the  use  of  cold  water  in  these  cases,  for 
the  reason  that  it  appeared  to  lower  the  vitality  of  the  parts  already 
bruised,  and  disposed  them  to  slough.  After  the  inflammation  has 
abated,  in  a few  day^s  extension  may  be  made  by  a weight  attached 
to  the  leg  by  two  lateral  strips  of  adhesive  plaster  running  up  its 
sides  and  hanging  over  the  foot  of  the  bed. 

When  the  inflammation  and  suppurative  action  have  still  more 
decreased,  there  will  be  no  objection  to  treat  the  case  with  the  appara- 
tus employed  in  simple  fracture.  Indeed,  in  ordinary7  cases  of  com- 


GENERAL  TREATMENT  OF  FRACTURES. 


355 


pound  fracture  the  apparatus  may  be  immediately  applied,  taking  care 
that  the  bandages  be  sufficiently  loose  to  allow  for  subsequent  swelling, 
otherwise  dangerous  results  may  occur  in  the  shape  of  mortification 
from  excessive  pressure. 

The  complications  of  this  class  of  fractures  are  pyaemia,  erysipelas, 
and  tetanus,  which  are  to  be  treated  upon  principles  applicable  to  those 
diseases. 

Complicated  Fractures. — Should  a dislocation  accompany  frac- 
ture, every  means  should  be  safely  tried  to  effect  the  reduction  of  the 
dislocation  first,  by  pressing  with  the  fingers  upon  the  upper  fragment, 
accompanying  it  at  the  same  time  with  proper  manipulation  of  the 
limb,  which  may  be  rendered  still  more  manageable  by  fastening 
it  with  straps,  or  a roller,  to  a board  extending  beneath  its  whole 
length ; if  these  means  succeed,  the  fracture  may  then  be  reduced  in  the 
usual  way ; on  the  contrary,  if  they  do  not,  the  limb  should  be  placed 
in  the  best  possible  position  for  union  of  the  bone  to  take  place  in  a 
right  line.  When  consolidation  has  been  completed,  gentle  attempts 
may  again  be  made  to  reduce  the  dislocation  by  manipulation,  but  at 
this  period  of  the  case  success  will  rarely  reward  the  surgeon’s  efforts. 

The  complication  of  rupture  of  bloodvessels  and  nerves,  and  exten- 
sive lacerations  of  the  soft  tissues,  are  to  be  treated  by  measures  appro- 
priate to  those  injuries,  the  former  accident  requiring  ligature,  and  the 
latter  the  use  of  sutures  and  adhesive  strips. 

General  Treatment  of  Fractures. — In  the  treatment  of  a frac- 
ture it  should  be  a surgeon’s  first  care  by  a scrutinizing,  minute,  and 
carefully  conducted  examination  to  find  out  exactly  what  the  condi- 
tion of  the  bone  may  be.  The  greatest  tenderness  and  expedition 
compatible  with  the  ascertainment  of  the  desired  information,  should 
be  exercised,  for  any  improper  or  rude  manipulations  not  only  inflict 
uncalled  for  suffering  upon  the  patient,  but  they  also  materially  influ- 
ence his  subsequent  recovery.  It  will  be  the  best  plan,  when  any 
lengthy  examination  is  necessary,  to  put  the  person  under  the  influ- 
ence of  chloroform,  which  will  not  only  obviate  pain,  but  will  secure 
the  additional  advantage  of  enabling  the  surgeon  to  make  a more 
thorough  examination  unopposed  by  the  struggles  of  the  patient  or 
the  contraction  of  the  muscles.  When  the  fracture  is  clearly  made 
out  the  indications  of  treatment  are  to  be  fulfilled ; of  these  there  are 
three  principal  ones  which  naturally  present  themselves : first,  to  re- 
duce the  fracture;  second,  to  retain  the  fragments  of  the  broken  bone 
in  a proper  position  after  the  reduction ; third,  to  counteract  subse- 
quent complications. 

Reduction. — It  was  formerly  a question  among  surgeons  as  to  the 
proper  time  for  reduction;  whether  to  wait  for  the  inflammation  and 
swelling  to  subside  before  manipulative  interference,  or  to  proceed 
with  the  manipulation  immediately.  The  general  experience  of  the 
ablest  surgeons  in  Europe  and  America  have  decided  the  latter  plan 
to  be  the  best,  and  it  is  the  one  now  almost  universally  practised. 

The  means  for  accomplishing  the  reduction  are,  first,  extension  and 
counter-extension  employed  conjointlj'- ; and  second,  coaptation.  Ex- 
tension is  the  force  applied  to  the  lower  fragment  of  a broken  bone, 


356 


GENERAL  CONSIDERATION  OF  FRACTURES. 


and  counter-extension  is  tlie  opposing  force  acting  in  exactly  the  con- 
trary direction  ; coaptation  is  merely  the  kneading  and  pressure  upon 
the  soft  parts  about  the  injured  point,  exercised  with  a view  of  shoving 
the  fragments  into  their  normal  situation. 

The  opinions  of  surgeons  are  somewhat  different  as  to  the  exact 
points  to  which  the  extending  and  counter-extending  bands  should  be 
affixed.  English  writers  commonly  recommend  that  they  be  applied 
directly  to  the  fragments  themselves  some  distance  above  and  below 
the  place  of  fracture;  while  the  French  surgeons  deem  it  more  ad- 
vantageous to  place  them  upon  those  sections  of  the  limb  connected 
with  the  fragments  above  and  below. 

The  advocates  of  the  first  method  contend  that  by  their  plan  a 
more  effective  and  direct  force  can  be  brought  to  bear ; while  those 
of  the  second  method,  admitting  the  advantage  gained  by  applying 
the  bands  in  this  manner,  urge  that  at  the  same  time  that  greater  force 
is  exerted,  the  muscles  will  be  stimulated  to  stronger  contractions  by 
the  local  irritation  thus  caused,  which  will  more  than  counterbalance 
the  gain  in  power. 

The  truth  in  this,  as  in  most  questions  of  the  kind,  lies  midway 
between  the  extremes,  and  the  judicious  surgeon  will  use  one  or  the 
other  plan  as  best  suits  the  exigencies  of  the  particular  case  he  is  called 
upon  to  treat.  During  the  efforts  at  reduction  the  limb  should  be 
held  in  that  position  which  most  thoroughly  relaxes  those  muscles 
opposing  the  replacement  of  the  fragments  in  their  normal  situation; 
usually  one  of  moderate  flexion  will  be  found  the  best. 

The  two  forces,  extension  and  counter-extension,  should  at  first  he 
made  in  the  direction  of  the  axes  of  the  fragments  upon  which  they 
act ; that  is,  in  the  direction  of  the  displacement ; when  the  ends  of  the 
bone  are  in  this  manner  disentangled  the  forces  must  be  brought  to 
bear  in  a straight  line  until  the  reduction  is  accomplished,  which 
should  be  furthered  by  pressing  with  the  fingers  upon  the  displaced 
pieces. 

If  the  fracture  is  transverse,  it  can  readily  be  imagined  how  the 
reduction  may  be  effected  and  consolidation  of  the  bone  obtained 
with  little  or  no  shortening  of  the  limb ; but  the  case  is  different  in 
oblique  fracture  in  which  it  is  almost  impossible  by  any  manipulation 
to  bring  the  fragments  into  exact  contact,  and  sustain  them  until  the 
repair  is  effected,  without  more  or  less  shortening.  In  fifty  cases  of 
which  I have  notes,  of  gunshot  fracture  of  the  long  bones,  the  shorten- 
ing varied  from  one  inch  the  minimum,  to  four  and  a half  inches  the 
maximum.  The  next  object  after  the  reduction  has  been  accom- 
plished, is  to  maintain  the  fragments  immovable  until  union  occurs. 
Opinions  of  surgeons  as  to  the  best  position  in  which  the  limb  should 
be  placed  to  secure  this  result  have  varied.  The  straight  posture  was 
recommended  by  Hippocrates  and  generally  practised  by  surgeons 
until  the  eighteenth  century,  when  Broomfield  and  Pott  advised  and 
practised  the  plan  of  keeping  the  limb  flexed.  The  former  method 
has  met  with  many  able  supporters,  both  in  Europe  and  America,  and 
in  the  latter  country  I believe  it  is  most  commonly  pursued,  except 
in  fractures  of  the  lower  third  of  the  femur.  These  remarks,  of  course, 


GENERAL  TREATMENT  OP  FRACTURES. 


357 


apply  to  fractures  of  the  lower  extremities ; for,  perhaps,  with  the  ex- 
ception of  fracture  of  the  olecranon,  all  injuries  of  this  kind  in  the 
upper  extremities  are  treated  in  the  bent  position.  From  a remote 
period  surgeons  have  sometimes  employed  certain  mechanical  con- 
trivances or  machines  to  effect  reduction,  such  as  the  bars  of  Hippo- 
crates, the  plinthium  of  Nileus,  the  glossocomes  of  Galen  and  Pare, 
and  in  later  times  the  adjuster  of  Jarvis,  but  in  this  class  of  injuries 
these  are  entirely  unnecessary,  inasmuch  as  no  greater  amount  of  force 
is  required  than  can  be  exercised  by  the  natural  powers  of  the  surgeon 
and  of  his  assistants. 

Retention. — There  are  great  difficulties  encountered  in  fulfilling  the 
second  indication;  position  will  accomplish  something,  but  the  greatest 
dependence  must  be  put  upon  properly  constructed  appliances,  of 
which  there  are  a great  many  varieties.  There  is  perhaps  no  branch 
of  surgery  in  which  more  genius  has  been  displayed  in  invention  than 
in  this  one,  and  it  will,  therefore,  be  proper  to  devote  some  space  to 
a consideration  of  the  general  features  and  character  of  the  apparatus 
that  are  now  employed. 

i Splints  are  the  most  indispensable  and  important  means  used  in  the 
treatment  of  fracture.  To  adapt  them  to  the  great  variety  of  injuries 
of  this  nature  occurring  daily,  they  are  required  to  be  made  in  vari- 
ous forms,  of  different  sizes,  and  of  several  materials. 

Wooden  splints,  of  all  others,  from  their  general  utility,  efficiency, 
accessibility,  and  simplicity  of  construction,  have  al  ways'  and  do  now 
enjoy  the  largest  share  of  professional  patronage,  and  this  is  truly  well 
deserved  when  we  consider  the  ease  with  which  any  person  may,  with 
a knife  and  a piece  of  soft  white  pine,  linden,  or  any  such  light  strong 
material,  prepare  splints  well  adapted  to  the  treatment  of  most  any 
case  of  fracture  in  which  splints  are  needed.  An  additional  recom- 
mendation is,  that  these  materials  may  be  obtained  without  cost,  and 
are  to  be  found  very  conveniently  at  hand. 

In  these  encomiums  we  do  not  wish  to  be  understood  as  including 
those  carved  splints  furnished  by  surgical  instrument-makers  and 
bandagists;  but  should  this  description  of  splint  be  desired,  the 
surgeon  should  superintend  its  construction  in  order  that  it  may  be 
adapted  to  the  case  in  which  it  is  to  be  used,  for  it  would  rarely 
happen  that  any  one  of  these  contrivances  would  possess  that  form 
and  size  adapting  it  to  the  treatment  of  a case  for  which  it  was  not 
made. 

As  to  the  matter  of  form,  splints  vary : some  are  straight,  as  those 
of  Desault  for  fracture  of  the  femur ; some  angular  or  curved,  as 
Phvsick’s  splint  for  the  elbow ; others  are  shaped  to  resemble  the  out- 
lines of  the  part  to  which  they  are  applied,  as  Pott’s  splint  for  fracture 
of  the  leg,  the  palette,  and  foot-board ; while  a third  class  are  grooved 
in  various  degrees  to  fit  the  irregularities  of  parts.  Splints  may  also 
be  entire,  or  notched  or  perforated  to  enable  the  turns  of  the  roller  or 
other  fastenings  to  be  more  effective  in  holding  them  to  the  limbs. 

The  size  of  splints  is  a matter  of  importance  both  as  regards  their 
neat  appearance  and  effectiveness ; for  when  they  are  clumsy  the 
general  appearance  of  the  dressing  will  be  marred  and  they  cannot  be 


358 


GENERAL  CONSIDERATION  OF  FRACTURES. 


so  securely  or  accurately  fixed  to  tlie  parts  beneath.  Those  materials 
should  be  selected  which,  when  reduced  to  the  lightest  and  thinnest 
laminae  possess  a sufficient  degree  of  toughness  and  strength  to  main- 
tain the  limb  immovable;  the  thinnest  splints  need  rarely  to  be  less 
than  one-sixth  of  an  inch  nor  the  thickest  more  than  three-eighths  of 
an  inch  upon  their  edge.  Their  width  should  be  sufficient,  as  a general 
rule,  to  prevent  the  bandage  pressing  upon  the  edges  of  the  limb 
between  them,  which  might  displace  the  fractured  bone ; a result  that 
has  not  unfrequently  happened  in  putting  splints  on  the  forearm. 
Their  length  is  also  to  be  carefully  attended  to;  in  fracture  of  the 
lower  part  of  the  fibula  and  of  the  upper  third  of  the  humerus,  if  the 
splints  are  too  short,  as  I have  seen  them  applied,  they  do  not  serve 
the  purpose  for  which  they  are  intended. 

Besides  wood,  splints  may  also  be  made  of  horn  or  whalebone,  or 
the  tough  inner  bark  of  various  trees,  which,  when  dipped  in  hot 
water  are  susceptible  of  being  moulded  to  the  limbs  with  accuracy. 
In  cases  of  emergency,  the  flexible  twigs  of  trees,  thin  reeds  or  straw 
rolled  up  in  a piece  of  cloth,  will  also  supply  good  splints. 

Pads  are  usually  prepared  for  splints  of  chaff  or  bran,  inclosed  in 
sacks  of  the  proper  length  and  width;  these  materials  make  cooler 
and  more  easily  adaptable  cushions  than  wool  or  curled  hair,  which  are 
sometimes  used.  Another  convenient  and  neat  plan  is  to  inclose  the 
splint  in  a little  sack,  leaving  one  of  its  ends  open,  through  which  cot- 
ton-batting is  stuffed,  until  a sufficiently  thick  cushion  is  obtained 
upon  one  side  of  the  splint,  when  the  mouth  of  the  sack  is  sewed  up. 
A more  expeditious  method  still  is  to  lay  the  cotton-batting  upon  a 
splint  and  inclose  them  both  with  a roller  bandage. 

M.  Gariel  has  recommended  the  employment  of  air-cushions,  made 
of  India-rubber,  which  may  be  inflated  through  a tube  connected  with 
them  to  the  desired  extent.  Fig.  291  shows  these  pads 
Fig.  291.  separated  from  the  splints.  Fig.  292  represents  the 
cushions  connected  with  the  splints,  and  applied. 

Pasteboard  is  a cheap,  efficient,  and  widely  diffused 
substance,  to  be  found  in  every  house  in  some  shape  or 

Fig.  292. 


Air-cushions  for  splints. 


other,  paper  boxes,  bandboxes,  etc.,  and  is  well  adapted  to  the  prepa- 
ration of  splints.  It  is  thrown  into  commerce  bv  the  manufacturer, 
made  of  different  sizes,  from  No.  1,  the  frailest,  to  No.  10.  the  stoutest 
article;  for  the  lower  extremities  No.  7 will  be  sufficiently  stifi  to 
make  splints  of ; aud  for  the  upper  extremities  No.  d or  6. 

The  method  of  preparing  these  splints  is  altogether  simple,  and 


GENERAL  TREATMENT  OF  FRACTURES. 


359 


with  a little  experience  a very  good  mould  of  any  portion  of  the  body 
may  be  obtained.  The  pasteboard  is  dipped  in  hot  water  until  it  is 
sufficiently  soft  to  be  moulded  to  the  surface,  to  which  it  is  confined 
by  a roller  bandage ; when  nearly  dry  the  pasteboard  is  removed,  and 
properly  trimmed  by  a pair  of  shears,  or,  better,  by  the  instrument 
invented  by  M.  Seutin  for  this  purpose  (Fig.  293). 


Fig.  293. 


To  make  the  most  perfect  models  in  pasteboard  M.  Mercie  (Mercie, 
Appareils  modele-s,  ou  nouveau  systhne  de  deligation,  Gland,  1858)  has 
proposed  to  obtain  an  exact  pattern  of  each  extremity  by  projecting 
upon  a flat  ground  those  curved  surfaces  which  determine  its  out- 
ward configuration;  for  instance,  in  procuring  a projection  of  the 
lower  extremity  he  selects  a person  of  average  stature,  and  applies  a 
roller  bandage  from  the  toes  to  the  groiu,  where  a spica  is  formed,  a 
solution  of  starch  is  smeared  over  this,  and  a second  roller  is  laid  on  in 
the  same  manner  as  the  first,  then  more  starch.  When  the  bandage  is 
quite  dry  it  is  removed  by  an  incision  extending  from  a point  midway 


Fig.  294. 


the  dorsum  of  the  foot  to  the  middle  of  Poupart’s  ligament ; the  model 
is  then  moistened  with  a wet  sponge,  spread  out  upon  a large  sheet 


860 


GENERAL  CONSIDERATION  OF  FRACTURES. 


of  paper,  and  its  margins  traced  out  with  a lead  pencil.  A line  drawn 
from  the  apex  of  the  heel  to  a point  over  the  ischium  will  divide  the 
bandage  into  an  external  and  internal  splint ; if  a piece  two  inches 
wide  be  cut  from  the  middle  of  each  of  these,  four  splints  will  be 
formed,  two  for  the  thigh,  and  an  equal  number  for  the  leg,  so  that 
they  may  be  used  singly  or  combiuedly,  according  to  the  judgment  of 
the  surgeon  or  the  necessities  of  the  case.  In  the  same  manner,  a pro- 
jection may  be  made  of  the  upper  extremity,  blow,  from  the  hori- 
zontal projection,  or  outlines  traced  upon  the  paper,  any  number  of 
splints  may  be  proposed.  Fig.  294  shows  the  projection  of  the  thigh; 
the  external  splint  for  a person  of  average  height  will  measure  in  its 
perpendicular  twenty-five  inches,  and  the  inner  one  seventeen  inches; 
for  heights  above  and  below  this  it  is  only  necessary  to  increase  or 
diminish  the  paper  pattern  with  the  scissors. 

Fig.  295  shows  a projection  of  the  leg;  the  length  of  the  pattern  is 
twenty-four  inches. 


Fig.  295. 


In  Fig.  296  the  pattern  for  the  arm  is  shown,  taken  from  a starch 
bandage,  which  has  been  divided  from  the  apex  of  the  olecranon  to 

the  posterior  extremity 
Flg>  29 b-  of  the  fold  of  the  axilla 

posteriorly,  and  from  the 
middle  of  the  bend  of  the 
elbow  to  the  acromion  an- 
teriorly ; the  outer  pattern 
is  fourteen  inches,  and 
the  inner  is  eight  inches 


Horizontal  projection  for  making  splints  for  the  arm. 


iong. 

The  projection  of  the 
forearm  is  obtained  from 
a starch  bandage  extend- 
ing  from  the  roots  of  the 
fingers  to  the  elbow,  and 
removed  by  two  incisions, 
one  along  the  radial,  and  the  other  along  the  ulnar  border  of  the  forearm; 
when  these  are  spread  out  and  traced  upon  paper,  they  give  the  appear- 
ance seen  in  Fig.  297,  the  posterior  pattern  being  eighteen  inches  long, 
and  the  anterior  one  fourteen  inches. 

After  the  pasteboard  splints  have  been  cut  upon  these  patterns 
they  are  immersed  in  warm  water,  and  when  sufficiently  soft  are 


GENERAL  TREATMENT  OF  FRACTURES. 


361 


drawn  out  and  moulded  accurately  to  every  point  of  the  surface 
which  they  are  intended  to  cover,  with  the  fingers ; a roller  bandage 


Fig.  297. 


Horizontal  projection  for  making  splints  for  the  forearm. 


is  then  applied  to  hold  the  splints  in  contact  with  the  skin ; at  the 
expiration  of  an  hour  or  two  the  splints  will  be  sufficiently  dried  to 
retain  their  shape,  when  they  are  to  be  removed  and  placed  in  an  up- 
right position  before  the  fire,  or  in  a current  of  air  to  insure  their 
thorough  desiccation.  Should  any  wound  exist,  that  part  of  the  paste- 
board corresponding  with  it  may  be  first  softened,  and  then  removed 
with  the  shears. 

Fig.  298. 


Fig.  299. 


Pasteboard  splints  for  the  forearm. 


Fig.  298  shows  the  appearance  of  splints  prepared  upon  these 
models  for  the  thigh,  and  Fig.  299  those  for  the  forearm.  They  form 


362 


GENERAL  CONSIDERATION  OF  FRACTURES. 


Fie.  300. 


accurate  moulds  of  the  limbs,  and,  when  properly  padded  and  applied, 
nothing  can  be  better  for  retaining  the  reduction  of  fracture  than  they. 
Any  fear  of  their  strangulating  the  parts  by  inordinate  pressure,  when 
applied  as  shown  below,  may  be  entirely  dispelled,  inasmuch  as  the 
surgeon  has  the  limb  beneath  his  observation  constantly,  and  can 
regulate  at  his  pleasure  the  amount  of  pressure  he  designs  the  splints 
to  make. 

The  splints  having  been  prepared,  they  are  applied  by  placing 
within  them  layers  of  cotton-batting  so  as  to  form  a soft  bed,  upon 
which  the  limb  reposes;  a roller  bandage,  or  a 
few  strips  of  elastic  ribbon,  will  suffice  to  main- 
tain the  splints  in  their  proper  position.  The 
mode  of  applying  the  apparatus  is  seen  in  Fig. 
300. 

Gutta-percha  is  now  furnished  the  surgeon, 
rolled  in  sheets  from  a sixteenth  to  a'quarter  of 
an  inch  in  thickness;  the  thinner  ones  will  be 
required  in  fractures  of  the  smaller  bones,  while 
for  the  larger  bones,  sheets  from  an  eighth  to  a 
quarter  of  an  inch  thick  are  necessary.  Should 
the  article  be  only  attainable  in  masses,  it  may 
be  softened  in  warm  water,  and  made  into  sheets 
by  kneading  it  with  the  fingers  and  afterwards 
rolling  it  out  with  a cylinder  of  wood. 

It  requires  a good  deal  of  tact  to  make  a neat 
and  serviceable  gutta-percha  splint ; for  the  mate- 
rial, immersed  in  warm  water  too  long,  becomes 
very  soft  and  difficult  of  management,  sticking 
to  the  fingers  or  anything  it  touches.  I have 
usually  pursued  a plan,  in  manipulating  with 
gutta-percha,  similar  to  that  described  by  Dr. 
Hamilton  in  his  Treatise  on  Fractures  and  Dis- 
locations. He  says  that  “ when  constructing  from 
this  material  a thigh-splint,  we  should  order  a 
very  large  tin  pan,  or  some  open  flat  tray,  in 
which  tve  may  lay  the  splint  at  full  length.  If 
the  splint  is  required  to  be  twelve  inches  long, 
and  six  wide,  we  must  cut  it  about  sixteen 
inches  long  by  eight  wide,  so  as  to  allow  for  the 
contraction  which  always  takes  place  more  or 
less  when  the  hot  water  is  applied.  It  is  then  to 
be  laid  upon  a sheet  of  cotton  cloth  of  more  than  twice  the  width  of 
the  splint,  in  order  that  the  cloth  may  envelop  it  completely  when  it 
is  folded  upon  it;  and  the  cloth  should  be  enough  longer  than  the 
splint  to  enable  us  to  handle  and  lift  it  by  the  two  ends  without 
immersing  our  fingers  in  the  hot  water.  Besides,  if  the  gum  is  not 
thus  covered  and  supported,  it  will  adhere  to  the  vessel,  to  the  fingers, 
to  the  surface  of  the  limb,  and  indeed  to  whatever  else  it  may  come 
in  contact  with ; it  may  even  fall  to  pieces,  or  become  very  much 
stretched  and  distorted  by  its  own  weight.  The  cloth  cover  will  gene- 


Mode  of  applying  a paste- 
board splint  in  fracture  of 
the  leg. 


GENERAL  TREATMENT  OP  FRACTURES. 


363 


j rally  adhere  to  the  splint,  and  may  be  permitted  to  remain  upon  it 
permanently. 

“Place  the  splint,  thus  covered,  in  the  basin,  and  pour  on  the  water 
at  or  near  th%  temperature  of  boiling.  As  soon  as  it  is  sufficiently 
softened,  lift  it  carefully,  and  lay  it  over  the  limb,  and  by  its  own 
weight  it  will  adjust  itself  to  the  surface,  or  it  may  be  moulded  with 
the  hands  or  by  pressing  it  against  the  limb  with  a pillow.  If  it  does 
not  harden  rapidly  enough,  this  process  may  be  hastened  by  sponging 
the  outer  surface  with  cold  water;  and  as  soon  as  it  has  acquired 
sufficient  firmness  to  support  itself,  it  may  be  removed  and  immersed 
in  a pail  of  cold  water  or  placed  under  a hydrant ; after  this,  it  is  to 
be  neatly  trimmed  and  dried,  when  it  is  ready  for  use.” 

Benjamin  Welsh,  of  Lakesville,  Conn.,  has  made  quite  convenient 
splints  by  covering  both  sides  of  the  gutta-percha  with  thin  flexible 
laminae  of  wood;  they  may  be  accurately  adapted  to  the  surface  by 
softening  them  in  hot  water.  By  frequent  use,  the  wood  is  apt  to 
separate  from  the  gum,  and  the  splint  becomes  worthless.  Fig.  301 
6hows  Welsh’s  splints  for  the  forearm. 


Fig.  301. 


Welsh’s  splints  for  the  forearm. 


Very  neat  and  strong  apparatus  may  be  prepared  with  paper  in  the 
following  manner : Take  of  coarse,  porous  paper,  of  any  kind,  a large 
sheet,  and,  having  spread  it  out  upon  a table  or  any  flat  surface,  rub 
into  its  interstices  a solution  of  starch,  and  repeat  the  process  upon  the 
other  side;  then  cut  the  sheet  into  strips  from  eight  to  twelve  inches 
long  and  two  inches  wide.  To  apply  them,  first  shave  the  surface  of  the  . 
fractured  limb  thoroughly,  and,  after  the  fracture  is  reduced,  envelop 
it  in  a layer  of  cotton-batting,  which  is  held  in  its  place  by  an  assistant 
or  by  a few  threads  tied  around  it,  while  the  surgeon  puts  on  the 
starched  strips  from  below  upwards,  each  overlapping  a third  of  the 
width  of  its  predecessor,  after  the  manner  of  the  bandage  of  Scultetus, 
until  the  whole  limb  or  the  desired  extent  of  surface  is  covered.  Lay 
over  these  three  or  four  vertical  strips,  placed  at  equal  distances  apart, 
and  then  another  circular  layer;  thus  alternate  the  direction  of  the 
strips  three  or  four  times,  or  until  the  splint  shall  have  acquired 
sufficient  strength  to  answer  its  purpose.  In  twenty-four  hours  the 
apparatus  will  be  hard  and  dry,  though  it  will  be  well  to  provide 
against  possible  accidents  during  the  intervening  time  by  applying 
two  lateral  splints  and  a roller  bandage.  Its  removal  may  be  accom- 
plished by  dividing  it  into  lateral  or  antero-posterior  sections  with 
Seutin’s  pliers. 


364 


GENERAL  CONSIDERATION  OF  FRACTURES. 


Sole-leather  makes  an  excellent  splint ; it  softens  readily  in  water, 
may  be  easily  moulded  to  the  limb,  and,  desiccating,  forms  a hard, 
resisting  shell.  The  splint  may  be  cut  out  of  the  leather  upon  the 
patterns  already  described  for  making  pasteboard  splints.  After  the 
action  at  Wilmington,  N.  C.,  I applied  the  leather  splints  to  some  ten 
or  twelve  cases  of  fracture  of  the  arms  and  legs,  with  gratifying  results. 

Another  form  in  which  leather  is  used  is  to  glue  to  a sheet  of 
buckskin  a thin  lamina  of  wood,  and,  after  it  is  dried,  the  wood  is 
cut  in  narrow  strips.  This  makes  the  most  unsatisfactory  apparatus 
possible ; it  can  neither  be  neatly  nor  accurately  applied  to  any  sur- 
face, at  least  those  that  I have  tried,  contained  in  the  allowance  table 
of  the  Medical  Department  of  the  Navy. 

Felt,  or  any  sort  of  old  stout  cloth,  saturated  with  a solution  of 
shellac,  containing  half  a pound  of  this  gum  dissolved  in  a quart  of 
alcohol,  and  dried,  will  also  make  good  splints  at  little  expense.  The 
following  method  may  be  pursued  in  their  preparation  : Lay  the  cloth 
upon  a flat  surface,  and  with  a brush  give  it  a good  coating  of  the 
solution,  which  should  then  be  thoroughly  dried  in  a current  of  air; 
after  which  three  or  four  more  applications  may  be  made  in  a similar 
manner.  The  cloth  is  now  to  be  folded  upon  itself,  and  pressed  with 
a hot  flat-iron  until  its  sides  adhere  ; repeat  the  doublings  and  ironing 
three  or  four  times,  when  the  requisite  thickness  will  be  obtained. 

To  apply  such  a splint,  first  reduce  the  fracture;  and  having  soft- 
ened shellaced  cloth  in  hot  water,  lay  it  upon  the  limb,  previously 
swathed  in  a layer  of  cotton-batting,  and  press  upon  it  with  the  hands 
in  every  direction  until  it  is  closely  in  contact  with  the  surface;  then 
put  a roller-bandage  over  it.  The  adjustment  of  this  splint  should  be 
quickly  done,  as  it  hardens  in  ten  or  fifteen  minutes. 

The  “ moulding  tablet”  is  a name  given  by  Mr.  Alfred  Smee  to  a 
contrivance  of  his  prepared  in  the  following  manner  : Take  a piece  of 
coarse  old  cotton  cloth;  spread  it  on  a table,  and  apply  to  its  surface, 
with  a brush,  a mixture  prepared  by  adding  common  whiting  to 
mucilage  of  gum-arabic,  until  the  latter  has  acquired  the  consistence 
of  thick  paste ; then  double  the  cloth  upon  itself,  and  permit  it  to  dry, 
when  a tough,  hard  board  will  result,  well  adapted  for  making  light 
and  strong  splints.  In  using  them  they  are  to  be  softened  with  hot 
water,  squeezed  from  a sponge. 

The  common  glue,  melted  in  the  usual  manner  in  a kettle,  and 
when  cold  having  about  a fifth  part  of  its  bulk  of  alcohol  added,  will 
form  a good  elastic  and  durable  bandage.  It  may  be  applied  in  the 
following  manner:  Envelop  the  limb  in  a layer  of  cotton-batting,  over 
this  put  a roller-bandage  from  below  upwards,  which  is  then  smeared 
with  the  glue;  another  roller  is  placed  over  this,  and  glued  in  the 
same  manner  as  the  first ; a third  roller  is  applied,  and  coated  with 
glue,  when  the  dressing  is  finished  by  a bandage  put  over  the  whole. 
The  limb  should  be  left  at  rest  from  twelve  to  twenty-four  hours, 
when  the  bandage  will  be  sufficiently  hard  to  be  cut  through  its 
whole  length,  and  the  margins  trimmed  with  the  scissors,  so  that  an 
interval  of  a quarter  of  an  inch  will  be  left  between  them.  Along  the 
margins  holes  are  now  to  be  punched,  and  “oeillets”  inserted  into 


GENERAL  TREATMENT  OF  FRACTURES. 


365 


them,  through  which  a soft  lacing  cord  is  to  be  passed.  In  this  appa- 
ratus the  compression  may  be  graduated  by  the  cord;  it  is  perfectly 
elastic,  and  may  be  removed  from  the  leg  with  ease  by  simply  press- 
■ ing  its  sides  asunder. 

The  metals  used  for  metallic  splints  are  iron,  copper,  lead,  and 
zinc — particularly  the  former — under  the  forms  of  tinned  sheets  and 
wire-gauze.  Of  the  tinned  sheets,  or,  as  it  is  more  commonly  called, 

1 tin,  very  light  splints  can  be  prepared  by  bending  them  into  proper 
shape  to  fit  the  limb  after  having  been  cut  roughly  into  the  outline 
of  the  parts ; to  confer  additional  lightness  they  may  also  be  perfo- 
rated  with  holes.  The  proper  shape  is  conferred  upon  wire-gauze  by 
modelling  it  upon  casts  of  the  limbs  in  plaster  of  Paris  or  wood,  and 
binding  it  with  strong  wire.  The  advantages  claimed  for  splints 
made  in  this  way  are  that  they  will  permit  the  perspiration  to  escape 
freely,  allow  fluid  applications  to  be  made  without  impairing  their 
stability ; and  lastly,  are  sufficiently  flexible  to  be  closely  fitted  to  the 
parts  beneath.  But  these  advantages  are  more  apparent  than  real; 
for  the  cotton-batting  used  with  most  all  of  this  class  of  splints  will 
serve  as  an  effective  absorbent,  so  that  no  more  inconvenience  will 
result  from  the  exuded  moisture  in  using  them  than  those  made  of 
wire;  wire-gauze  cannot  be  so  nicely  adjusted  to  the  limbs  either  as 
pasteboard  and  leather;  and  as  to  their  permitting  the  employment  of 
water-dressings,  any  other  sort  of  splint  will  do  the  same  without 
impairing  its  strength,  if  it  is  properly  managed.  There  are  excep- 
tional cases,  however,  in  which  they  may  be  used  with  advantage ; 
for  instance,  in  compound  fracture  of  the  elbow-joint,  with  profuse 
suppuration;  and  in  gunshot  wounds  of  this  nature  I have  employed 
the  wire  splint  with  satisfaction.  Bauer,  of  New  York,  has  displayed 
a good  deal  of  ingenuity  in  constructing  this  kind  of  apparatus,  and  it 
cannot  be  denied  that  they  are  gotten  up  very  artistically;  but  their 
comparatively  high  cost,  and  inferiority  to  splints  made  of  other  mate- 
rials, will  prevent  them  from  coming  into  general  use. 

Immovable  Apparatus. — The  French  surgeons  have  conferred  this 
name  upon  a class  of  splints  of  which  we  shall  now  speak.  They 
were  undoubtedly  employed  long  ago  by  the  Arabs,  and  some  of  the 
Eastern  nations,  as  the  writings  of  Bhazes  and  Albucasis  sufficiently 
prove.  It  is  stated  that  the  idea  of  treating  fracture  by  the  immova- 
ble apparatus,  in  modern  times,  first  occurred  to  M.  Gfeoffroy,  sug- 
gested by  an  examination  of  some  ancient  Egyptian  relics. 

Theodoric,  Lanfranc,  and  Guy  de  Chauliac,  employed  this  form  of 
bandage ; and  the  latter  recommended  the  use  of  a mixture  of  various 
gummy  and  resinous  substances  in  its  composition.  Ambrose  Pare 
directed  his  friend  Bichard  Hubert,  who  was  attending  him  for  a frac- 
tured leg,  “ to  fortify  the  sides  of  his  limbs  with  junks  made  of  tents 
or  little  sticks,  and  lined  with  linen  cloth.”  He  also  gives  the  fol- 
lowing formula  for  a mixture  which  “ should  be  applied  all  around 
a broken  leg;”  frankincense,  mastich,  aloes,  and  Armenian  bole, 
of  each  an  ounce;  alum  and  resin,  of  each  three  drachms;  flour,  a 
pound  and  a half ; and  a sufficient  number  of  eggs  to  make  a paste. 
In  1768  Moschati  used  compresses  and  bandages  saturated  with  the 


366 


GENERAL  CONSIDERATION  OF  FRACTURES. 


white  of  eggs ; and  Le  Dran  added  to  these,  in  preparing  his  band- 
ages, vinegar,  Armenian  "bole,  starch,  and  plaster. 

After  Moschati,  Baron  Larrej  was  the  first  to  revive  the  use  of  the 
immovable  apparatus,  and  it  was  the  authority  of  his  name  and  prac- 
tice which  caused  it  to  be  generally  adopted  by  surgeons  every- 
where. The  solidifying  liquid  used  by  this  distinguished  surgeon  was 
composed  of  camphorated  brandy,  Goulard’s  extract,  and  the  whites 

of  eggs  beaten  up  with  water.  The  dressing 
Fig-  302.  consisted  of  the  bandage  of  Scultetus,  two 

lateral  splints  made  of  unbroken  straw,  com- 
presses, and  a splint  cloth. 

This  apparatus  was  used  by  Larrey,  not 
only  in  fractures,  but  in  severe  contusions 
and  wounds,  and  in  the  former  case  it  was 
never  removed  until  consolidation  had  taken 
place,  unless  some  adverse  accident  com- 
pelled him  to  do  so. 

M.  Seutin  ( Traite  de  la  Methode  amovo-ina- 
movible,  Bruxelles,  1849),  Surgeon-in-Chief 
of  the  Belgian  army,  began,  in  1834,  to 
make  trials  of  various  solidifying  liquids, 
and  of  these  found  a solution  of  starch  to  be 
the  best.  He  at  first  used  a contrivance  simi- 
lar to  that  of  Baron  Larrey,  but  subsequently 
contrived  a different  one,  which  he  designated 
as  the  “movable-immovable”  apparatus  (ap- 
pareil  amovo-inamovible) ; he  adjusted  its 
several  parts  in  the  following  manner  (Fig. 
302):  Having  reduced  the  fracture,  and  made 
the  surface  of  the  limb  uniform  by  compresses 
of  amadou  or  tow,  he  applies  a roller  bandage 
from  the  toes  upwards ; reaching  the  superior 
portion  of  the  member  a reverse  turn  is  made, 
and  a second  layer  is  put  over  the  first  from 
above  downwards.  A solution  of  starch  is 
now  smeared  over  the  whole  surface  either 
with  a brush  or  with  the  hand.  Beneath  the 
turns  of  the  bandage  along  the  anterior  sur- 
face of  the  limb,  and.  in  contact  with  the  skin, 
he  places  a greased  cord  called  by  him  a com- 
pressimetre  (compressi  metre),  the  extremities 
of  which  hang  externally  and  are  looped;  by 
pulling  upon  these  loops  the  amount  of  pres- 
sure exercised  by  the  bandage  can  be  ascer- 
tained. Over  the  roller  pasteboard  splints  are 
laid,  having  been  previously  softened  in  hot 

Seutin's  apparatus  for  fractures  of  water  thoroughly  Starched  UpOU  both  sides, 

the loivu  and  accurately  modelled  to  the  limb;  while 

these  are  beiug  held  by  an  assistant  he  covers  them  with  a roller  band- 
age, proceeding  from  below  upwards,  and  returning  exhausts  the  roller 


GENERAL  TREATMENT  OP  FRACTURES. 


367 


by  several  turns  about  tbe  foot  or  ankle  as  the  case  may  be,  taking  care 
always  to  have  the  toes  and  fingers  exposed.  An  additional  quantity 
of  starch  is  again  uniformly  distributed  over  the  apparatus  with  the 
palm  of  the  hand,  and  the  dressing  is  complete.  In  fractures  of  bones 
of  the  leg,  M.  Seutin  employs,  instead  of  the  roller  form  of  the  band- 
age of  Scultetus,  interposing  between  the  first  and  second  a posterior 
pasteboard  splint,  and  between  the  second  and  third  bandages  two 
lateral  splints ; all  of  these  layers  are  to  be  starched,  except  the  first. 
; Seutin  objects  to  placing  a starch  bandage  in  direct  contact  with  the 
skin,  as  it  is  apt  to  produce  irritation  and  possibly  erysipelas. 

While  the  bandage  is  desiccating,  which  occupies  a period  from 
thirty  to  forty  hours,  he  advises  precautionary  splints  to  be  applied  to 
the  sides  of  the  limb  to  sustain  it.  When  the  drying  is  completed, 

; Seutin  directs  the  hardened  shell  to  be  cut  open  along  its  anterior  sur- 
face, using  the  cord  previously  spoken  of  as  a guide ; the  limb  may 
now  be  inspected,  and  defects,  if  there  are  any  in  the  dressing,  corrected, 
such  as  the  cording  or  knotting  of  the  rollers ; unequal  pressure  should 
be  carefully  guarded  against  by  the  use  of  compresses,  or  what  is  bet- 
ter, cotton-batting.  If  everything  has  gone  on  nicely,  the  valves  should 
be  drawn  together  and  supported  by  the  turns  of  a roller,  or  two  or 
three  elastic  cords  encircling  the  limb. 

Should  any  wound  exist,  that  portion  of  the  pasteboard  opposite  to 
it  may  be  removed  with  the  scissors,  having  previously  been  softened 
with  water;  or,  instead  of  removing  the  piece  entirely,  it  will  be  better 
to  let  it  remain  as  a sort  of  valve  (Fig.  304),  so  that  when  the  sore 
is  dressed  it  may  be  again  covered  by  the  paste- 
board, which  will  prevent  any  bulging  out  of 
the  tissues  beneath. 

Yelpeau  has  also  used  extensively  the  im- 
movable apparatus  in  the  treatment  of  fractures. 

He  employs  a solution  of  dextrine  instead  of 
starch,  made  of  the  following  articles:  Dextrine, 
one  hundred  parts ; camphorated  brandy  and 
hot  water,  of  each  fifty  parts.  The  dextrine  is 
placed  in  a vessel  and  the  camphorated  brandy 
is  gradually  added,  stirring  the  while  until  the 
materials  are  intimately  mixed  and  the  solution 
is  of  the  consistence  of  honey;  the  water  is  now 
poured  in,  which  will  render  the  mixture  about 
as  thin  as  a light  soup  when  it  is  ready  for  use. 

The  fracture  is  first  reduced,  and  the  limb 
covered  with  a protective  bandage,  when  the 
roller,  soaked  in  the  solution  of  dextrine,  is 
laid  on,  beginning  at  the  extremity  of  the  limb 
and  ascending  in  the  usual  manner,  taking  care 

: of  reverses  that 

in  this  manner  is 
not  sufficiently  strong,  Yelpeau  introduces,  like 
Seutin,  pasteboard  splints  among  its  folds,  having  previously  softened 


mj  inane  tne  requisite  numoe 
the  bandage  may  not  pucker 
When  the  bandage  formed 


Fig.  303. 


Immovable  apparatus  with 
valve  over  seat  of  injury. 


368  GENERAL  CONSIDERATION  OF  FRACTURES. 

them  in  camphorated  brandy,  which  will  hasten  the  drying  process, 
which  requires  about  four  or  five  hours.  An  opening  may  be  left 
opposite  any  wound  by  leaving  an  interval  between  the  turns  of  the 
rollers  as  they  are  being  put  on. 

The  quantities  of  dextrine  used  by  M.  Velpeau  in  preparing  his 
bandages  are  as  follows:  For  fracture  of  the  thigh,  eighteen  ounces; 
for  the  leg,  ten ; and  for  the  arm,  seven.  It  is  important  to  obtain  a 
good  quality  of  dextrine,  as  a good  deal  of  that  thrown  into  commerce 
is  utterly  worthless  for  the  purpose  of  preparing  bandages.  The  sort 
that  should  be  selected  is  of  a yellowish  color  and  not  so  crumbly 
and  crepitating  between  the  fingers  as  those  specimens  containing 
starch ; it  strikes  a deep  red  color  with  the  tincture  of  iodine. 

Splints  of  Plaster  of  Paris. — These  were  employed  long  ago  by  the 
Moors  of  Spain,  and  by  Hubenthal  in  1819 ; but  their  first  introduc- 
tion is  commonly  ascribed  to  Dieffenbach,  of  Berlin.  The  method  was 
to  surround  the  fractured  portion  of  the  limb  with  a large  quantity  of 
the  plaster,  so  as  to  form  a sort  of  box  about  it.  Prepared  in  this  way 
the  splints  were  heavy  and  objectionable,  inasmuch  as  they  needed 
often  to  be  cut  away  with  hammer  and  chisel  to  expose  the  parts  be- 
neath rendered  tender  and  painful  by  the  confined  perspiration  and 
by  the  increased  heat  thereby  produced ; they  are  besides  in  constant 
danger  of  becoming  constrictive  to  such  a degree  as  to  produce  morti- 
fication, though  I have  seen  several  cases  of  fractured  thigh  brought 
to  a happy  issue,  by  the  Dutch  surgeons,  with  these  splints. 

These  objections  do  not  hold  against  the  plaster  bandages  now  to 
be  described,  which  have  been  particularly  studied  by  MM.  Mathijssen 
and  Van  de  Loo,  of  Holland,  and  Prof.  Pirogoff,  of  St.  Petersburg 
( Gazette  Hebdomadaire,  Aug.  185T).  There  are  several  methods  of 
preparing  them,  but  I have  usually  pursued  the  directions  given  by 
Van  de  Loo,  who  uses  either  rollers  or  the  bandage  of  Scultetus.  To 
make  plastic  splints  of  rollers,  he  recommends  you  to  “spread  upon  a 
table  a piece  of  cotton  cloth,  free  from  starch  and  softened  by  use,  or 
of  flannel,  five  feet  long  by  a foot  and  a half  wide ; upon  this  cloth 
scatter  at  least  a pound  and  a quarter  of  very  dry  plaster  in  powder, 
which  should  be  made  to  penetrate  it  as  much  as  possible  by  stroking 
it  with  the  open  palm ; then,  after  having  removed  the  excess  of 
plaster,  we  turn  the  piece  over,  and  perform  the  same  operation  upon 
the  other  side.  Both  sides  of  the  cloth  being  well  impregnated  with 
plaster,  we  cut  it,  remaining  still  on  the  table,  into  strips  one  and 
a half  or  two  inches  wide,  which  can  be  neatly  done  by  previously 
making  grooves  upon  it,  at  equal  distances,  by  means  of  a thin  cord 
stretched  across  its  surface,  and  which,  raised  with  the  fingers  by  its 
centre,  is  permitted  to  strike  upon  it;  then  we  roll  them  upon  the 
table  with  much  less  firmness  than  we  do  ordinary  rollers.  The  roller 
bandages  keep  very  well,  providing  we  place  them  in  a tight  box. 

“ In  order  to  use  them,  we  take,  if  we  have  to  do  with  a fracture  of 
the  leg,  the  member  being  previously  surrounded  with  an  ordinary 
roller  bandage,  one  of  these  plastered  rollers,  which  we  moisten  well 
with  water,  with  the  aid  of  a sponge  (the  water  being  introduced  into 
both  ends  of  the  roller),  and  apply  it  as  an  ordinary  roller,  with 


GENERAL  TREATMENT  OF  FRACTURES. 


369 


tliis  difference,  that  the  turns  should  cover  each  other  three-fourths  or 
four-fifths  of  their  width;  in  the  same  manner  we  moisten  and  apply 
a second  and  a third  roller,  and  so  on,  taking  care  to  place  the  initial 
extremity  of  a succeeding  one  below  that  one  applied  just  before.  In 
this  way  the  apparatus  can  be  better  unrolled. 

“If  we  do  not  wish  to  make  any  reverses,  we  cut  the  roller  each 
time  that  a change  of  direction  becomes  indispensable. 

“In  order  to  give  the  bandage  the  desirable  smoothness  and  elegance, 
it  suffices  to  pass  lightly  over  its  surface  a slightly  moistened  sponge 
every  time  two  or  three  rollers  are  applied. 

“In  order  to  make  a fenestrum,  we  go  to  work  in  the  following 
manner:  Arriving  near  a wound,  for  example,  we  cut  the  roller  and 
commence  upon  its  opposite  side,  and  continue  thus  until  we  have 
passed  beyond  the  wound. 

“Should  we  wish  to  render  the  bandage  removable  (amovible),  we 
cut  it  by  means  of  Seutin’s  scissors,  and  we  obtain  removable  valves 
that  answer  special  indications,  which  will  be  laid  down  further  on. 

“ Should  we  wish  to  remove  it,  it  is  well  to  moisten  it  a little,  to 
prevent  the  liberation  of  the  dust  of  the  plaster.” 

There  are  also  two  ways  of  making  plaster  splints  with  the  bandage 
of  Scultetus.  “ In  the  first,  we  arrange,  in  the  form  of  the  bandage 
of  Scultetus,  twenty -five  or  thirty  plastered  strips  upon  a cushion  fur- 
nished with  a napkin ; they  should  cover  each  other  three-fourths  of 
their  width.  Upon  these  we  place  a layer  of  ordinary  strips,  and  on 
this  apparatus,  thus  prepared,  we  place  the  fractured  member. 

“After  having  applied  the  ordinary  strips,  we  moisten,  with  the  aid 
of  a sponge,  one  or  two  plastered  strips,  which  we  apply  immediately, 
and  we  continue  thus  until  all  the  plastered  strips  shall  be  applied. 

“ In  order  to  fenestrate  the  bandage,  or  to  render  it  removable,  we 
go  to  work  as  for  the  apparatus  prepared  with  the  rollers.” 

In  the  second  method,  “ upon  a cushion  covered  with  a napkin  we 
place  first  a plastered  strip,  over  which  we  spread  a strip  without 
plaster,  of  the  same  width,  but  two  fingers’  width  longer,  in  such  a 
manner  as  to  extend  beyond  the  first  a finger’s  width  at  each  end,  and 
with  the  same  precaution  to  cause  it  to  overlap  also  the  plastered  strip 
another  finger’s  breadth  in  the  direction  of  its  width.  The  plastered 
strip  which  has  the  same  dimensions  in  this  direction  as  the  strip 
without  plaster  will  then  offer  a plastered  border  to  unite  with  the 
other  pieces  of  the  apparatus.  These  first  two  strips  being  thus 
arranged,  we  spread  a plastered  strip  upon  one  without  plaster,  in 
lengthening  out  the  apparatus  the  width  of  a finger  at  each  addition ; 
upon  this  fresh  strip  another  without  plaster  is  placed,  and  so  on  suc- 
cessively until  the  whole  bandage. may  be  prepared. 

“ Then  we  put  the  member  upon  the  apparatus,  which  is  moistened 
with  a sponge  from  which  the  water  has  been  squeezed  out,  and  one 
applies  first  a strip  without  plaster  and  one  with  plaster  on  the  same 
side,  and  immediately  we  adjust  in  the  same  manner  the  opposite  ends. 
We  continue  thus  until  the  whole  apparatus  is  laid  on. 

“ In  this  manner  there  is  always  a strip  without  plaster  between 
two  strips  with  plaster,  and  vice  versa" 

24 


370 


GENERAL  CONSIDERATION  OF  FRACTURES. 


In  preparing  the  bivalved  apparatus,  Yan  de  Loo  describes  two 
methods.  In  the  first  “ we  cut  six  plastered  strips  from  two  and  a 
half  to  three  inches  wide,  and  sufficiently  long  that  they  may  extend 
from  the  superior  part  of  the  apparatus  we  propose  to  apply  to  three 
fingers’  width  below  the  soles  of'  the  feet,  supposing,  in  the  mean  time, 
that  we  are  operating  upon  the  inferior  member. 

“ Then  we  arrange  upon  a cushion,  protected  with  a towel,  twenty- 
five  or  thirty  plastered  strips,  also  from  two  and  a half  to  three  inches 
wide,  of  which  the  longest  should  be  about  ten  and  the  shortest  six 
inches  for  a man’s  leg.  Upon  these  plastered  strips  we  place  simple 
strips  (without  plaster);  next  we  lay  the  fractured  limb  upon  the 
apparatus,  and  we  apply  the  simple  strips;  then  we  take  one  of  the 
six  long  strips  which  have  been  mentioned  above,  we  moisten  it  well, 
and  apply  it  upon  the  external  side  of  the  member  from  its  superior 
part  to  below  the  sole  of  the  foot;  we  place  another  of  them  in  the  same 
manner  upon  the  internal  side,  leaving  between  the  latter  and  the  pre- 
ceding an  interval  of  one  or  two  widths  of  the  finger;  this  done,  we 
moisten  and  apply  the  twenty-five  or  thirty  strips  with  plaster  upon 
them,  which  are  arranged  upon  the  towel ; we  finish  the  bandage  by 
moistening  and  applying  successively  the  four  remaining  long  plas- 
tered strips — that  is  to  say,  two  upon  the  external  side  and  two  upon 
the  internal— taking  care  to  cover  the  first  two.” 

It  is  understood  that  in  the  case  where  the  plastered  strips  which 
compose  the  apparatus  of  Scultetus  should  present  a greater  length 
than  is  necessary  to  apply  them  upon  the  margins  of  the  valves,  we 
should  cut  them  as  they  are  applied,  that  they  may  not  encroach  upon 
the  space  remaining  free  between  the  two  halves  of  the  bandage. 

To  render  this  apparatus  immovable,  we  fill  up  the  space  remaining 
free  between  the  two  valves  with  a little  tow.  and  we  apply  three  or 
four  plastered  strips  crosswise,  or  better  one  or  two  strips  of  suitable 
width  in  the  direction  of  the  width  of  the  interval,  concealing  it  com- 
* pletely.  To  establish  the  removability  of  the  bandage,  it  will  suffice  to 
take  away  these  strips. 

If  the  apparatus  is  intended  to  envelop  the  whole  of  the  inferior 
extremity,  twenty  more  of  these  strips  are  necessary,  of  which  the 
longest  should  be  seventeen  and  the  shortest  eleven  inches,  as  well  as 
six  long  strips,  extending  from  the  knee  to  the  superior  part  of  the 
apparatus. 

In  the  second  method  he  directs  that  “we  arrange  two  layers  of 
strips  without  plaster,  and  superposed.  We  place  upon  the  latter  a 
piece  of  old  blanket  or  flannel  cut  in  proportion  to  the  length  of  the 
leg,  in  a manner  to  embrace  the  posterior  half  or  two-thirds  of  its 
circumference.  This  piece  being  previously  impregnated  with  plaster 
upon  its  two  faces,  and  upon  that  one  which  will  be  in  contact  with 
the  limb,  we  arrange  a layer  of  fine  tow.  The  apparatus  being  thus 
prepared,  we  place  the  extremity  upon  it  after  having  suitably 
moistened  the  plastered  pieces,  and  we  apply  the  whole  by  means  of 
the  superficial  range  of  separate  strips. 

The  application  of  the  first  layer  of  strips  being  completed,  we 
apply  upon  the  anterior  part  of  the  leg  a fresh  layer  of  tow,  or  a 


GENERAL  TREATMENT  OF  FRACTURES. 


371 


compress  without  wrinkles,  and  above  this  another  piece  of  blanket 
or  flannel  equally  impregnated  with  plaster,  and  suitably  moistened, 
which  covers  the  anterior  of  the  leg  and  encroaches,  the  width  of  two 
fingers,  on  each  side,  upon  the  posterior  shell.  The  whole  is  then 
fastened  by  the  range  of  strips  which  have  remained  unapplied. 

“ Should  we  wish  now  to  inspect  the  anterior  part  of  the  leg,  we 
have  only  to  detach  the  strips,  and  we  can  raise  the  piece  of  woollen 
cloth  with  the  plaster  on  it,  which  protects  this  region,  and  afterwards 
reapply  it,  when  we  have  examined  the  limb  and  finished  the  dress- 
ings required  by  the  condition  of  the  parts. 

“ Supposing  that  the  section  should  be  made  at  the  external  side 
of  the  leg,  for  example,  in  front  or  behind  the  fibula,  the  hinge  (or 
junction)  will  consequently  be  found  upon  the  internal  side,  and  extend 
the  whole  length  of  the  bandage.  All  being  arranged  and  the  limb 
placed  upon  the  apparatus,  we  commence  by  applying  the  layer  of 
simple  strips,  as  that  is  ordinarily  practised.  We  adjust  subsequently 
the  first  three  plastered  strips  which  embrace  the  whole  of  the  lower 
part  of  the  leg.  With  the  three  following  strips  we  behave  differ- 
ently in  order  to  obtain  at  first  a hinge,  that  is  to  say,  a cloth  connec- 
tion which  serves  as  a pivot  to  the  valves  and  permits  them  to  be 
opened  without  ever  compromising  the  form  of  the  plastered  shells. 
At  the  moment  when  we  apply  them  we  should  take  the  precaution 
to  cut  them  in  their  passage  upon  the  hinge.  An  iuterval  of  a fraction 
of  a line  is  permitted  between  the  two  ends  produced  b}7  this  section, 
and  we  continue  the  application  of  these  upon  the  rest  of  the  circum- 
ference of  the  member.  The  two  strips  which  then  follow  are  placed 
entire,  that  is  to  say,  without  being  cut,  in  such  a manner  that  they 
shall  perform,  at  a later  period,  the  office  of  hinges.  In  short  we 
continue  thus  the  alternate  application  of  these  cut  strips,  and  two 
entire  strips,  in  such  a way  that  after  the  section  we  obtain  a hinged 
apparatus  perfectly  ‘movable-immovable,’  applying  itself  exactly  to 
the  whole  limb,  and  not  liable  to  be  thrown  out  of  shape  in  conse- 
quence of  the  different  dressings  or  examinations  that  the  condition 
of  the  limb  demands. 

“In  order  to  render  the  plaster  bandages  perfectly  ‘ movable,’ it 
suffices  to  trace  a groove  in  the  plaster  yet  soft,  immediately  after  the 
application  of  each  apparatus,  with  the  aid  of  the  edge  of  a spatula, 
the  back  of  a knife,  or  even  with  a small  piece  of  coin.  The  groove 
thus  traced  suffices  to  constitute  a joint  which  will  permit  the  most 
extended  movements  to  the  valves  that  will  be  formed  ulteriorly  by 
the  section  of  the  bandage.  For  the  inferior  extremity  we  can,  if  we 
wish  it,  trace  two  lateral  grooves  in  order  to  obtain  two  valves; 
whereas  a single  one  will  generally  suffice  for  the  superior  extremity.” 

In  using  plaster  with  water  alone  the  dressing  has  to  be  conducted 
with  inconvenient  haste,  that  it  may  not  harden  before  all  the  pieces 
of  the  bandage  are  in  their  intended  positions.  The  “ setting”  of  the 
plaster  may  be  delayed  by  mixing  with  the  water  which  is  added  to 
it  various  foreign  materials.  Those  most  commonly  employed  for 
this  purpose  are  starch,  dextrine,  and  glue. 

When  starch  is  employed,  its  solution  should  be  hot  while  the 


372 


GENERAL  CONSIDERATION  OF  FRACTURES. 


plaster  is  being  mixed  with  it;  the  proportion  being  equal  quantities 
of  the  two  materials,  which  must  be  incorporated  little  by  little  in  an 
open  dish.  This  mixture  may  be  now  used  with  the  various  forms 
of  Van  de  Loo’s  bandages  already  described. 

A solution  of  dextrine  has  the  same  effect  as  starch ; it  is  used  cold. 
The  proportion  of  these  articles  may  be  varied  to  suit  the  emergencies 
of  each  case:  to  obtain,  for  instance,  the  consolidation  of  a bandage 
in  fifteen  or  twenty  minutes,  we  may  employ  a pound  of  the  plaster 
to  about  a pint  of  water  containing  one  ounce  of  dextrine  in  solution, 
the  plaster  being  added  in  small  quantities  at  a time  to  the  solution, 
which  should  be  stirred  constantly  during  the  preparation  of  the 
mixture. 

I have  been  more  in  the  habit  of  using  glue  in  preparing  plaster 
splints,  and  prefer  it  to  any  other  article.  The  proportion  will  vary 
according  as  the  consolidation  is  required  to  take  place  sooner  or  later. 
M.  Richet,  who  employs  these  materials  in  making  his  bandages,  says 
that  fifteen  grains  of  glue  to  a quart  of  water  will  not  sensibly  retard 
the  setting  of  the  plaster,  but  that  twenty-one  grains  will  delay  it 
twenty  or  twenty-five  minutes,  seventy-seven  grains  from  three  to  five 
hours,  and  one  hundred  and  fifty-four  grains  from  ten  to  twelve  hours. 
He  directs  the  solution  to  be  used  at  a temperature  of  68°  or  77°  Fahr., 
and  that  the  plaster  be  incorporated  with  it  until  a paste  is  made, 
which  may  be  applied  either  with  the  hand  or  a spatula.  M.  Richet 
prefers  rollers  made  of  tarlatan — a sort  of  a coarse  gauze ; in  the 
absence  of  this,  coarse  muslin  may  be  used.  He  always  protects 
the  parts  beneath  with  a dry  roller,  and  places  his  plastered  rollers 
over  this,  and  if  the  bandage  is  required  to  have  more  strength,  as 
when  an  entire  extremity  has  to  be  inclosed,  the  paste  may  be  smeared 
upon  its  outer  side  with  the  hand,  and  subsequently  rendered  smooth 
with  a spatula. 

As  a provisional  dressing  for  fractures,  and  under  circumstances 
where  more  efficient  splints  cannot  be  obtained,  the  apparatus  of  Scul- 
tetus  will  be  found  of  real  service.  It  consists  of  separate  strips, 
straight  splints,  pads,  and  a splint- cloth.  The  strips  may  be  from  an 
inch  and  a half  to  two  inches  wide,  and  long  enough  to  encircle  the 
limb,  and  to  overlap  at  each  end  three  or  four  inches ; these  are  im- 
bricated from  below  upwards,  each  strip  covering  two-thirds  of  the 
width  of  its  predecessor.  The  straight  splints  may  be  made  of  any 
material,  such  as  wood,  gutta-percha,  pasteboard,  or  straw  tied  into 
little  bundles  by  a cord  wrapped  spirally  about  them,  but  most  com- 
monly the  first  is  employed.  The  pads  are  usually  prepared  of  oat- 
chaff,  though  any  soft  material  may  be  used,  as  cotton,  flannel,  lint, 
etc.  The  splint-cloth  is  made  of  muslin  or  other  stout  cloth,  and 
should  be  sufficiently  long  to  go  around  the  circumference  of  the  limb 
three  or  four  times. 

The  apparatus  is  thus  applied,  for  instance,  in  fracture  of  the  thigh: 
Five  strips  of  muslin,  three  for  the  thigh  and  two  for  the  leg,  are  laid 
upon  the  mattress ; upon  these  the  splint-cloth  is  spread,  bearing  on 
its  upper  surface  a sufficient  number  of  imbricated  strips  to  reach  from 
the  foot  to  the  groin ; the  fracture  is  now  to  be  reduced,  and  the  limb 


FRACTURE  OF  THE  SKULL. 


373 


laid  upon  the  strips,  which  are  drawn  over  it  from  below  upwards. 
Two  lateral  splints  are  now  selected,  the  external  one  long  enough  to 
extend  from  the  ilium  to  beyond  the  sole  of  the  foot,  and  the  internal 
one,  from  the  perineum  to  the  same  point ; and  an  anterior  splint  to 
reach  from  the  fold  of  the  groin  to  the  dorsum  of  the  foot.  The  late- 
ral splints  are  rolled  up  in  the  splint-cloth  from  each  of  its  ends 
towards  the  limb  until  but  a narrow  interval  remains  between  them 
upon  each  side  of  the  limb ; two  long  pads  are  now  introduced  in 
these  intervals  between  the  limb  and  splints,  while  a third  pad  is 
; placed  beneath  the  long  anterior  splint,  or  the  two  short  splints  used 
by  some  surgeons.  The  splints  arranged  in  this  manner  are  to  be  held 
by  assistants  until  the  surgeon  has  secured  them  to  the  limb  by  the  five 
strips  of  muslin  above  mentioned.  The  foot  can  be  prevented  from 
falling  to  either' side  by  placing  the  middle  portion  of  a strip  of  mus- 
lin upon  its  sole,  crossing  the  ends  upon  its  dorsum,  and  fastening  them 
with  pins  to  the  lateral  cushions. 

The  apparatus  may  be  prepared  in  a similar  way  for  fractures  of 
the  leg  and  arm,  though,  in  the  upper  extremities,  instead  of  the  strips 
the  roller  bandage  is  most  always  used  to  make  the  compression. 


CHAPTER  II. 

SECTION  I. 

, 

FRACTURES  OF  THE  BONES  OF  THE  SKULL  AND  FACE. 

Fracture  of  the  Skull. — Fractures  of  the  bones  of  the  skull  are 
the  result  of  exterior  violence,  and  often  involve  the  brain  and  its 
membranes  in  inflammation  and  suppuration.  These  complications 
require  the  most  active  medical  treatment,  depletion,  application  of 
cold,  purgation,  etc.  When  fragments  of  bone  are  driven  into  the  sub- 
stance of  the  brain,  or  the  tables  of  the  skull  are  beat  in  so  as  to  press 
upon  it,  the  case  demands  certain  surgical  procedures,  the  application 
of  the  trephine,  &c.,  which  are  more  properly  described  in  general  works 
on  surgery. 

The  mastoid  process  of  the  occipital  bone  has  been  rarely  broken 
off  by  direct  violence,  and  displaced  downwards  by  the  contraction  of 
the  sterno-cleido-mastoid  muscle. 

Treatment. — Incline  the  patient’s  head  to  the  injured  side,  and  retain 
it  in  the  position  either  by  the  figure  of  8 bandage  of  the  head  and 
axilla,  or  the  double  T of  the  forehead  and  chest. 

By  the  same  sort  of  violence  the  external  angular  process  of  the 
frontal  bone  may  be  broken  and  displaced  inwards  towards  the  eye, 
or  backwards  towards  the  temporal  fossa;  along  with  this  injury  there 
is  always  found  fracture  of  the  malar  bone  and  zygomatic  arch. 

In  the  treatment  of  such  a case  replace  the  fragment  by  pressure 


374 


SPECIAL  FRACTURES. 


with  the  fingers,  or  by  means  of  a lever,  if  there  be  a wound.  There 
is  no  tendency  to  displacement  by  muscular  action,  so  that  a pledget 
of  lint  dipped  in  cold  water  and  laid  upon  the  part  will  be  the  only 
dressing  required. 

If  the  injury  is  confined  to  the  frontal  bone,  there  will  be  no  fur- 
ther trouble ; not  so,  however,  if  the  eye  is  damaged,  or,  as  is  more 
often  the  case,  the  brain,  by  the  same  blow.  The  case  is  decidedly 
more  serious,  and  requires  a very  guarded  prognosis.  These  compli- 
cations are  to  be  met  by  active  antiphlogistic  measures. 

Fracture  of  the  Nasal  Bones  and  Cartilages.  Causes. — 
The  cause  of  fracture  of  the  nasal  bones  is  direct  violence,  such  as  is 
inflicted  by  blows  with  the  fist,  falls,  and  by  gunshot  wounds.  The 
fracture  may  be  simple  or  comminuted  ; pass  transversely  through 
the  lower  third  or  middle  of  the  bones,  or  vertically  in  a line  with 
their  length ; and  sometimes  the  separation  occurs  at  their  junction 
with  the  nasal  process  of  the  superior  maxillary.  Rarely  a single 
nasal  bone  is  broken.  In  these  cases  there  will  be  more  or  less  dis- 
placement, and  sometimes  fracture  of  the  septum  of  the  nose,  though 
the  latter  occasionally  happens  even  when  the  force  is  not  sufficient 
to  break  the  nasal  bones ; the  fracture  takes  place  generally  at  the 
junction  of  the  cartilage  with  the  bony  septum,  or  in  the  vertical 
nasal  plate.  The  cartilaginous  portion  of  the  bridge  of  the  nose  may 
also  be  bent  in  or  broken. 

The  displacement  occurs  backward  or  laterally,  according  to  the 
direction  of  the  force  brought  against  the  nose. 

Symptoms. — There  is  almost  immediately  great  swelling  of  the 
nose,  with  more  or  less  bleeding  from  it ; the  deformity  is  marked, 
and  the  fragments  may  be  moved  with  the  fingers,  or  with  a thin 
metallic  instrument,  as  probe  or  director,  introduced  into  the  nostrils. 
As  the  Schneiderian  membrane  is  sometimes  ruptured,  the  air  is 
driven,  during  expiration,  into  the  cellular  tissue  of  the  eyelids  and 
the  adjacent  parts,  producing  emphysema. 

When  the  force  causing  the  fracture  is  very  violent,  the  brain  and 
its  membranes  may  be  involved  in  inflammation  and  suppuration 
by  the  fracture  running  through  the  ethmoid,  sphenoid,'  or  frontal 
bones.  In  these  complications,  to  the  above  symptoms  there  may  be 
added  those  of  concussion,  and,  in  the  worst  cases,  coma. 

Diagnosis. — Should  the  case  be  seen  early,  and  a careful  examina- 
tion had,  there  can  be  little  difficulty  encountered  in  making  out  the 
exact  condition  of  the  nasal  bones ; at  a later  period  the  diagnosis  is 
exceedingly  difficult,  so  that  in  a large  number  of  cases  of  this  injury, 
from  the  great  swelling  which  ensues,  the  displacement  of  the  frag- 
ments passes  unrecognized  either  by  the  physician  or  by  the  patient. 
It  is  not  until  the  tumefaction  has  disappeared  that  the  marked  de- 
formity resulting  from  even  a trifling  displacement  of  the  fragments 
becomes  apparent,  and  induces  the  patient  to  seek  aid  of  the  surgeon 
at  a period  when  but  little  can  be  accomplished. 

Prognosis. — There  is  no  danger  to  be  feared  in  a case  of  simple 
fracture  of  the  nasal  bones,  though  when  the  ethmoid  and  frontal  are 
involved  in  the  fracture,  as  they  sometimes  are,  and  the  brain 


FRACTURE  OF  THE  NASAL  BONES  AND  CARTILAGES.  375 

damaged,  death  will  usually  result  from  the  injury,  and  hence  the 
prognosis  should  always  be  guarded  when  these  complications  are 
suspected  or  are  discovered  to  exist. 

The  frequency  of  deformity  following  this  injury  should  admonish 
us  not  to  commit  ourselves  by  any  assurances  as  to  the  ultimate  result 
of  the  case  in  this  particular. 

Occasionally,  also,  catarrh  and  obstruction  of  the  nostrils  will  be 
established  and  last  for  months;  in  other  cases,  obliteration  of  the 
nasal  duct,  giving  rise  to  fistula,  epiphora,  &c.,  has  been  noted ; and, 
rarely,  an  obstinate  ulceration  of  the  nasal  mucous  membrane  and 
cartilages. 

Treatment. — In  the  treatment  of  this  fracture  our  first  object  will  be 
to  make  a thorough  examination  of  the  nose,  and  as  this  is  exceedingly 
painful,  the  patient  may  be  put  under  the  influence  of  chloroform,  if 
it  is  necessary,  to  accomplish  this  purpose. 

The  reduction  of  the  fragments  may  be  effected  with  a thin  steel- 
grooved  director  or  probe,  passed  into  the  nares,  and  pressed  against 
the  bones  from  behind  forwards,  while,  with  the  fingers  placed  upon 
the  outside  of  the  nose,  counter-pressure  is  made.  In  this  manner  we 
must  endeavor  to  restore  the  natural  outlines  of  the  organ. 

When  the  replacement  has  been  effected,  as  there  are  no  muscular 
fibres  acting  upon  the  fragments,  they  generally  retain  their  position 
without  any  bandaging  whatever,  though  it  must  not  be  forgotten 
that  when  the  bones  are  broken  into  a number  of  fragments,  sneezing 
or  hawking  may  displace  them,  and  the  patient  should  therefore  be 
cautioned  to  abstain  from  these  actions  as  much  as  possible. 

Should  the  nose  incline  to  either  side,  a narrow  compress  should  be 
laid  upon  each  side  of  the  organ  after  it  has  been  restored  to  its  natu- 
ral position,  and  secured  in  place  with  the  double  T bandage  of  the 
nose,  avoiding  making  any  backward  pressure.  No  plugging  the 
nostrils  with  lint  should  be  had  recourse  to,  as  it  can  do  no  good ; 
and  this  will  be  evident  if  anatomical  structure  of  the  upper  and  an- 
terior portion  of  the  nares  is  considered.  The  space  where  pressure 
could  be  of  any  service  is  exceedingly  narrow,  and  it  is  very  question- 
able whether,  with  the  swelling  of  the  mucous  membrane,  it  could  be 
packed  with  lint.  The  same  objections  hold  against  the  use  of  appa- 
ratus having  levers  connected  with  them,  and  intended  to  be  intro- 
duced into  the  nostrils  to  support  the  bones. 

Consolidation  takes  place  rapidly,  and  after  the  lapse  of  seven  or 
eight  days  the  fragments  may  become  immovable. 

The  only  dressing  required  will  be  a light  cloth,  wrung  out  of  cold 
water,  laid  over  the  nose. 

The  excessive  hemorrhage  may  require  the  nostrils  to  be  tam- 
poned, an  operation  which  will  be  described  further  on. 

If  the  septum  of  the  nose  is  deviated  to  either  side,  we  should 
endeavor  to  press  it  into  its  natural  position  with  the  point  of  some 
blunt  instrument ; and  if  any  tendency  exists  to  a recurrence  of  the 
displacement,  the  nostrils  should  be  equally  padded  with  pellets  of  lint. 

Some  authors  recommend  the  use  of  a splint  of  the  exact  shape  of 
the  nose,  and  moulded  to  its  outside.  Dr.  Hamilton,  in  a case  in  which 


376 


SPECIAL  FRACTURES. 


the  bridge  of  the  nose  was  depressed  at  the  junction  of  the  osseous 
with  the  cartilaginous  portion,  and  the  tip  tilted  forwards,  restored  it 
to  its  natural  shape,  one  year  after  the  accident,  by  loosening  the 
depressed  cartilage  with  a point  of  a bistoury,  and,  having  passed  a 
ligature  through  it,  raised  it  to  its  proper  level,  where  it  was  retained 
by  tying  the  ligature  over  a gutta-percha  splint  accurately  fitted  to 
the  nose ; the  ligature  was  removed  in  two  days,  but  the  splint  kept 
on  two  weeks. 

Fracture  of  the  Superior  Maxillary  Bone. — Fracture  of  the 
superior  maxillary  bone  may  occur  in  its  body  or  in  its  processes. 
As  has  already  been  stated,  in  the  preceding  article,  its  nasal  process 
is  sometimes  broken  at  the  same  time  that  the  nasal  bones  are  crushed 
in.  The  alveolar  process  is  sometimes  damaged  by  violent  efforts  at 
extracting  teeth,  and  Le  Dran  records  a case  in  which  a man  had  that 
portion  of  the  alveolus  containing  the  last  four  molar  teeth  broken  off 
and  lodged  beneath  the  roof  of  the  mouth,  by  a cart-wheel  passing 
over  his  head ; the  palate  and  gums  remained  entire. 

In  other  instances  the  violence  is  so  great  as  to  fracture  the  body  of 
the  bone  and  its  palatal  process ; and  lastly,  in  gunshot  wounds,  both 
superior  maxillaries  may  be  destroyed.  Bibes  relates  a remarkable 
case  ( Dictionnaire  des  Sciences  Medicales,  tom.  xix.,  art.  Machoire),  in 
which  a soldier,  at  the  siege  of  Alexandria,  in  Egypt  (1801),  was 
wounded  by  a shell,  which  carried  away  the  right  malar  bone,  both 
upper  maxillaries,  the  greater  portion  of  the  lower  jaw,  the  nasal 
bones,  cartilages,  and  septum,  the  vomer,  and  a portion  of  the  ethmoid 
bone. 

Causes.- — From  the  firm  manner  in  which  the  superior  maxillaries 
are  wedged  in  among  the  other  bones  of  the  face,  it  requires  great 
and  direct  violence  to  break  them ; though  Richerand  and  J.  Cloquet 
each  record  a case  in  which  the  injury  resulted  from  counter-stroke; 
in  the  first  the  chin  and  head  were  acted  upon  by  two  opposite  forces, 
and  in  the  other  a violent  blow  was  inflicted  upon  the  chin  from  below 
upwards.  These  fractures  are  also  accompanied  with  more  or  less 
contusion  and  laceration  of  the  soft  parts,  and  sometimes  with  cerebral 
disturbance. 

Symptoms. — The  mobility  of  the  fragments,  when  pressed  with  the 
fingers,  the  irregularity  of  the  dental  arch,  if  the  fracture  pass  through 
it,  and  the  apparent  deformity,  will  generally  declare  the  nature  of  the 
case.  Extravasation  of  blood  into  the  orbit  will  sometimes  render 
the  eyeball  more  prominent. 

Prognosis. — From  the  amount  of  injury  necessary  to  cause  a fracture 
of  the  upper  jaw,  particularly  of  its  body,  we  should  be  exceedingly 
circumspect  in  delivering  a prognosis,  and  especially  when  there  is 
reason  to  suspect  that  either  the  brain  or  the  ethmoid  or  sphenoid 
bones  have  been  also  implicated  in  the  injury.  An  uncomplicated 
fracture  will  heal  rapidly  and  safely,  and  in  some  cases  it  is  astonish- 
ing how  soon  the  consolidation  occurs  even  when  the  fragments  are 
loosely  connected  with  soft  parts. 

When  the  malar  bone  is  driven  in  upon  the  autrum,  some  deformity 
will  remain  if  it  is  not  raised,  and  also  a displacement  of  a portion  of 


FRACTURE  OF  THE  SUPERIOR  MAXILLARY  BOME.  877 

the  orbital  process  of  the  superior  maxillary  will  result  in  the  same 
manner  and  force  the  ball  of  the  eye  forwards. 

Should  cerebral  symptoms,  as  coma,  delirium,  &c.,  set  in,  we  may 
infer  that  the  fracture  has  extended  to  the  bones  at  the  base  of  the 
skull,  which  will  render  hopes  of  recovery  very  slender  indeed. 

Treatment. — In  a fracture  of  the  nasal  process  of  the  superior  maxil- 
lary, which,  as  already  stated,  occurs  usually  with  a similar  injury  of 
the  nasal  bones,  the  treatment  should  be  conducted  in  the  same  manner 
as  for  it ; that  is,  the  reduction  must  be  attempted  with  a slender  steel 
instrument  introduced  into  the  nostrils,  while  pressure  is  made  with 
the  fingers  upon  the  outside  of  the  nose. 

When  a portion  of  the  alveolar  process  is  broken,  it  should  be 
restored  to  its  natural  position,  and  retained  there  by  the  simple 
expedient  of  closing  the  lower  teeth  upon  the  upper,  and  applying  a 
ding  bandage  for  the  lower  jaw.  If  this  plan  is  not  successful,  any 
flexible  and  strong  wire,  such  as  iron  or  silver,  may  be  used  to  tie  the 
loosened  teeth  to  the  firm  ones.  To  put  the  wire  in  place,  pass  its 
two  ends  between  the  teeth,  and  twist  them  together  with  the  fingers, 
or,  what  is  better,  with  a pair  of  long  pointed  pliers;  thread  or  silk 
■may  he  also  employed  for  the  same  purpose  as  the  wire. 

In  some  cases  a gutta-percha  splint,  moulded  to  the  palatine  vault 
and  the  teeth,  will  answer  admirably  in  supporting  the  broken  frag- 
ment. 

One  of  the  superior  maxillaries  may  be  so  loosened  from  its  con- 
nections with  its  fellow  and  the  other  bones  with  which  it  articulates, 
that  it  becomes  displaced  to  a considerable  extent ; the  palatine  pro- 
cesses are  separated  from  each  other  or  override.  In  this  case,  when 
the  reduction  has  been  accomplished  by  pressure  with  the  fingers  in 
the  mouth  and  a female  catheter  introduced  in  the  nostril,  the  gutta- 
percha splint  above  mentioned  may  be  applied,  and  the  jaws  held 
immovable  by  a sling  bandage.  A heavy  blow  struck  upon  the  malar 
bone  may  break  the  anterior  wall  of  the  antrum  and  depress  the 
cheek;  this  injury  is  commonly  attended  with  a fracture  of  the  alveo- 
ar  process.  In  this  case  an  effort  should  be  made  to  raise  the  malar 
bone  with  the  finger,  introduced  into  the  mouth  between  the  gum  and 
cheek,  behind  the  zygomatic  process. 

If  there  is  a wound  upon  the  face,  a lever  may  be  used  with  the  same 
object;  though  rather  than  permit  the  bone  to  remain  depressed  a 
small  incision  should  be  made  in  front  of  the  masseter  through  which 
he  lever  may  be  introduced  beneath  the  malar  bone. 

If  the  floor  of  the  antrum  is  broken  away,  the  point  of  the  finger 
nay  possibly  be  put  into  that  cavity  and  pressure  brought  to  bear 
lpon  the  posterior  surface  of  the  displaced  bone.  It  has  also  been 
■ecommended  to  extract  one  of  the  molars  so  that  a steel  instrument 
night  be  thrnst  into  the  antrum;  but  in  extensive  fracture  of  the 
ipper  maxillaries  this  plucking  out  of  the  teeth  is  not  unattended 
vitk  danger,  and  it  would  be  much  more  preferable,  in  order  to  gain 
Amission  into  the  antrum,  to  perforate  its  anterior  wall  and  use  a 
curved  lever. 

The  removal  of  loosened  fragments  of  the  upper  jaw  should  be 


378 


SPECIAL  FRACTURES. 


delayed  as  long  as  possible,  for  the  reason  that  union  does  occur  some- 
times under  the  most  unfavorable  circumstances. 

The  fractures  resulting  from  gunshot  are  to  be  treated  upon  the 
general  principles  already  laid  down,  and  although  large  portions  of 
the  upper  jaw  may  be  carried  away  and  frightful  deformity  succeed, 
yet,  after  the  lapse  of  some  months,  the  recuperative  efforts  of  nature 
do  a great  deal  in  remodelling  the  lacerated  parts  that  they  may  he 
better  able  to  perform  their  functions.  When  this  is  accomplished, 
the  patient’s  condition  may  be  made  much  more  comfortable  by  the 
use  of  appropriate  prosthetic  apparatus. 

Fracture  of  the  Malar  Bone.  Causes. — As  in  the  case  of  the 
other  bones  of  the  face,  fracture  of  the  malar  bone  implies  the  appli- 
cation of  great  direct  force  to  the  part,  as  the  kick  of  a horse,  and  is 
almost  always  accompanied  with  a fracture  of  the  superior  maxillary. 
A blow  upon  its  orbital  border  may  result  in  a fissure  of  this  bone 
alone.  In  a few  cases  observed  the  bone,  instead  of  being  fractured, 
seems  to  have  been  simply  displaced  ; its  orbital  margin,  being  tilted 
forwards  and  pressing  upon  the  eyeball,  interferes  with  its  movements. 

Diagnosis. — The  depression  of  the  cheek  and  mobility  of  the  frag- 
ments when  manipulated  with  the  fingers  will  sufficiently  establish 
the  nature  of  the  case. 

Prognosis. — Fracture  of  the  malar  bone  without  cerebral  complica- 
tions will  generally  heal  speedily,  and,  at  the  worst,  only  leave  some 
deformity;  while,  on  the  other  hand,  disturbance  on  the  part  of  the 
brain  indicates  associated  damage  to  the  neighboring  bones,  and 
renders  the  patient’s  recovery  extremely  doubtful. 

Treatment. — If  there  is  a displacement  of  the  fragments  of  the  malar 
bone,  they  should  be  restored  to  their  natural  position  in  the  manner 
already  pointed  out  in  the  previous  article.  After  the  reduction  is 
accomplished,  water-dressings  may  be  applied.  Cerebral  complica- 
tions must  be  met  by  appropriate  treatment,  according  to  their  nature. 

Fracture  of  the  Zygoma. — The  zygomatic  arch,  formed  by  the 
zygomatic  processes  of  the  malar  and  temporal  bones,  although  very 
slender,  is  yet  rarely  broken. 

Causes. — The  causes  are  blows  upon  the  malar  bone,  and  violence 
acting  directly  upon  the  arch  either  from  within  or  from  without. 
Two  cases  are  reported  in  which  the  injury  resulted  from  force 
applied  in  the  former  manner,  by  a pointed  instrument  thrust  into 
the  mouth  passing  out  at  the  temple  and  strikiug  the  arch. 

From  the  attachment  of  strong  ligamentous  and  muscular  fibre: 
to  the  borders  of  the  zygoma,  it  can  well  be  understood  that  there  car 
be  but  two  directions  in  which  displacement  may  occur,  namely,  in- 
wards and  outwards,  according  as  the  force  acts  from  within  or  from 
without. 

Symptoms. — The  naturally  curved  outline  of  the  zygoma  car 
readily  be  felt  with  the  fingers,  so  that  when  a case  of  fracture  is  seer 
early;  any  salient  or  re-entrant  angle  formed  by  the  fragments  of  th< 
broken  bone  in  the  temple  can  be  readily  felt;  they  may  also  be  mover 
so  as  to  develop  crepitus.  Should  any  sharp  point  of  bone  havi 


FRACTURE  OF  THE  INFERIOR  MAXILLARY  BONE.  379 


penetrated  the  masseter  muscle,  there  will  be  difficulty  in  moving  the 
lower  jaw,  and  in  some  instances  this  is  entirely  impracticable. 

Prognosis. — A simple  fracture  of  the  zygoma  is  of  little  moment, 
and  in  all  the  recorded  examples  union  has  taken  place  promptly. 
Stiffness  of  the  lower  jaw  will  gradually  pass  away. 

If  the  violence  has  been  very  severe  and  the  case  is  complicated 
with  fracture  of  the  facial  bones,  and  cerebral  disturbance,  the  danger 
will,  of  course,  be  in  proportion  to  the  extent  of  these  complications. 

Treatment. — If  the  fragments  of  the  broken  zygoma  form  a salient 
angle  in  the  temple,  it  may  be  depressed  to  the  natural  level  by 
pressing  upon  it  with  the  ball  of  the  thumb.  In  an  inward  displace- 
ment, on  the  contrary,  the  depressed  bone  should  be  raised  by  pressing 
: with  the  finger  upon  the  inside  of  the  cheek — a practicable  procedure 
when  the  fracture  is  near  the  malar  bone.  If  there  is  a wound,  an 
elevator  may  be  introduced  beneath  the  zygoma  and  its  elevation 
easily  accomplished ; if  the  skin  is  intact,  a small  incision  may  be 
made,  as  was  done  in  two  of  the  recorded  cases,  to  admit  the  point  of 
the  instrument. 

No  apparatus  is  required  after  the  reduction  is  effected,  as  the  frag- 
ments will  retain  their  position. 

Fracture  of  the  Inferior  Maxillary  Bone. — Although  the 
inferior  maxillary  bone  forms  so  prominent  a part  of  the  lower  portion 
of  the  face,  yet  it  is  not  frequently  fractured.  This  is  due,  in  a great 
measure,  to  its  mobility  and  arched  form. 

Causes. — In  a majority  of  instances  the  fracture  results  from  direct 
violence,  as  the  kick  of  a horse,  or  a blow  with  a club,  or  the  fist ; it 
has  also  resulted  from  counter-stroke,  as  when  a blow  struck  upon 
the  side  of  the  jaw  breaks  the  neck  of  the  condyle  upon  the  opposite 
side ; the  neck  may  also  be  fractured  by  a blow  upon  the  chin.  A 
third  example  of  this  injury  from  counter-stroke  is  where  the  angles 
of  the  inferior  maxillary  are  pressed  together  when  the  fracture  will 
occur  at  the  symphysis.  Portions  of  the  alveolar  process  are  some- 
times broken  off  by  unskilful  dental  operations.  Muscular  action  has 
also  been  recorded  as  an  occasional  cause. 

The  bone  may  be  fractured  in  its  body,  angles,  ascending  rami,  necks 
of  the  condyles,  or  in  the  coronoid 
process  (Fig.  304). 

When  the  body  of  the  bone  suf- 
fers the  line  of  fracture  will,  in  a 
majority  of  cases,  be  found  at  or 
near  the  mental  foramen.  Boyer 
denies  that  it  even  occurs  at  the 
symphysis,  yet  accurate  observers 
have  met  with  such  cases ; after  the 
naval  engagement  at  New  Orleans 
one  was  admitted  into  the  hospital 
under  my  charge.  The  fracture  re- 
sulted from  a glancing  shot  which 
carried  away  the  lower  lip,  and  thus  enabled  me  to  get  ocular  demon- 
stration of  the  position  of  the  injury.  The  patient  was  aged  twenty 


Fig.  304. 


Specimen  showing  three  forms  of  fracture  of  the 
lower  jaw. 


380 


SPECIAL  FRACTURES. 


years ; the  fissure  was  seated  exactly  vertical  between  the  two  middle 
incisors,  which,  though  loose,  were  not  dislodged  from  their  alveoli. 
The  young  man  made  a speedy  recovery,  and  I restored  the  lip  by  a 
plastic  operation. 

As  to  the  direction  of  the  line  of  fracture  in  the  body  of  the  bone, 
it  may  be  vertical,  oblique,  or  horizontal ; generally  it  is  backwards 
and  inwards,  so  that  the  posterior  fragment  will  ride  over  the  anterior, 
the  latter  (if  there  is  a fracture  upon  both  sides)  being  drawn  down- 
wards and  a little  backwards  by  the  digastricus,  genio-hyoid,  and 
genio-hyo-glossus  muscles. 

If  the  fracture  is  seated  at  the  angles,  the  insertions  of  the  masseter 
and  internal  pterygoid  muscles  will  hold  the  fragments  together  so 
that  there  will  be  little  displacement. 

One  or  both  necks  of  the  condyles  may  suffer  at  the  time  of  the 
infliction  of  the  injury;  the  external  pterygoid  muscle  will  draw  the 
condyle  upwards  and  inwards,  while  the  masseter  acting  upon  the 
angle  of  the  jaw  will  displace  the  lower  fragment  forwards  and  up- 
wards, throwing  the  mouth  open  a little  thereby;  if  the  fracture  is 
upon  one  side  only,  the  chin  will  be  turned  a little  to  the  sound  side. 

When  the  line  of  fracture  passes  through  the  coronoid  process  the 
only  displacement  that  occurs  is  by  the  temporal  muscle  pulling  that 
process  upwards. 

Symptoms. — Besides  the  displacements  above  described,  the  other 
symptoms  of  fracture  of  the  lower  jaw  are  mobility  of  the  fragments, 
which  can  in  nearly  every  case  be  developed  by  manipulation ; slight 
depression  in  front  of  the  external  meatus,  if  the  injury  is  seated  at 
the  neck  of  the  condyle,  resulting  from  the  upper  fragment  being 
drawn  forwards  and  inwards;  crepitus,  which  may  be  felt  when  the 
jaw  is  moved,  and  pain  at  the  point  of  injury.  A fracture  of  the 
coronoid  process  can  be  ascertained  by  introducing  the  finger  in  the 
mouth  and  feeling  the  anterior  edge  of  that  process  behind  the  last 
molar  tooth  when  any  existing  mobility  or  crepitus  would  be  perceived. 

The  presence  of  any  irregularity  of  the  dental  arch,  loosening  of 
the  teeth,  or  laceration  of  the  gums,  will  also  furnish  important  infor- 
mation as  regards  the  existence  and  seat  of  a fracture. 

Prognosis. — Fractures  of  the  alveolar  process  usually  result  favora- 
bly; the  bone  unites,  and  the  teeth,  if  they  have  been  loosened,  become 
firmly  fixed.  The  same  satisfactory  issue  will  usually  be  obtained  in 
single  fracture  of  the  body,  symphysis,  and  angles  of  the  bone.  When 
the  fracture  affects  both  sides  of  the  jaw,  or  the  necks  of  the  condyles, 
some  little  deformity  or  irregularity  of  the  dental  arch  will  often 
result  in  spite  of  the  best-conducted  treatment.  The  prognosis  in 
compound  and  comminuted  fracture  is  still  less  favorable,  implying 
the  infliction  of  greater  force  upon  the  face,  and  rendering  escape 
from  some  degree  of  deformity  much  less  probable.  Abscess  some- 
times occurs  in  these  cases,  giving  rise  to  tedious  and  troublesome 
exfoliations. 

In  rare  cases,  paralysis  of  the  muscles  of  the  lower  lip  and  convul- 
sions have  resulted  from  the  injury. 

In  making  the  prognosis  it  should  also  be  remembered  that  a heavy 


FRACTURE  OF  THE  INFERIOR  MAXILLARY  BONE.  381 

blow  struck  upon  the  chin  may  produce  serious  injury  to  the  hones 
at  the  base  of  the  skull,  hemorrhage  from  the  auditory  meatus,  hard- 
ness of  hearing,  and  buzzing  in  the  ears. 

Delayed  union  has  been  observed  in  some  cases ; according  to 
Sanson  union  of  the  coracoid  process  with  the  ramus  never  takes 
place  by  bone. 

Treatment. — The  reduction  of  a fracture  of  the  body  of  the  inferior 
maxilla,  either  single  or  double,  is  very  easily  accomplished  by  seizing 
the  anterior  fragment  and  raising  it  upwards  and  forwards  until  it  is 
exactly  level  with  the  posterior  one,  which  retains  its  natural  position ; 
the  adjustment  is  known  to  be  perfect  when  the  inferior  border  of  the 
bone  forms  a regular  and  unbroken  line.  In  fracture  of  one  or  both 
condyles  with  displacement  of  the  fragments  the  reduction  is  not  so 
easy;  for  it  will  be  necessary  at  the  same  time  that  the  jaw  is  being 
drawn  forward,  to  make  pressure  upon  the  condyle  with  the  tip  of  the 
finger  introduced  into  the  mouth,  so  as  to  force  it  outwards,  when  it 
may  be  clamped  between  the  lower  fragment  and  the  glenoid  cavity 
by  simply  pressing  the  chin  backwards  and  upwards. 

To  maintain  the  fragments  in  their  natural  position  various  contriv- 
ances have  been  suggested  and  employed  from  an  early  date.  One  of 
the  first  was  the  ligature,  which  is  to  be  applied  around  the  necks  of 
the  teeth  upon  opposite  sides  of  the  line  of  fracture,  and  tied  tightly. 
The  materials  of  which  the  ligature  is  made  may  be  any  strong  thread, 
or  silver,  gold,  or  platinum  wire. 

Baudens,  in  a case  of  very  oblique  fracture  complicated  with  a 
wound,  bound  the  fragments  together  by  means  of  a ligature  passed 
around  them  in  the  following  manner  : he  took  a long  needle  flexible  at 
its  middle,  and  perforated  with  two  eyes,  armed  with  a ligature  formed 
by  twisting  six  or  eight  threads  together ; the  fracture  having  been 
reduced,  while  the  fragments  were  steadied  with  the  thumb  and  index 
fin  ger  of  the  left  hand,  he  introduced  the  point  of  the  needle  at  the 
lower  margin  of  the  inferior  maxilla  and  carried  it  along  its  inner 
surface  beneath  the  gum  to  the  roots  of  the  tooth,  where  the  ligature 
was  pulled  into  the  mouth  from  the  nearest  eye ; the  needle  was  now 
withdrawn  to  the  lower  edge  of  the  jaw  and  passed  between  its  outer 
side  and  the  gum  into  the  mouth  again,  where  the  ligature  was  re- 
moved from  the  second  eye  ; thus  the  jaw  was  inclosed  in  a loop,  to  be 
secured  over  the  teeth  or  a splint  moulded  to  them.  Baudens  stated 
that  the  case  did  well,  and  the  ligature  was  removed  on  the  twenty- 
fourth  day. 

In  two  or  three  recorded  cases  the  ends  of  a broken  jaw  have  been 
perforated,  and  held  together  by  a metallic  suture. 

We  have  already  described  the  sling  and  crossed  bandages  for  the 
,aw,  sometimes  employed  in  the  treatment  of  fracture  of  this  bone.  As 
in  improvement  upon  these,  Dr.  J.  E.  Barton,  of  Philadelphia,  recom- 
mended a bandage  (Fig.  805),  which  he  applied  in  the  following  manner : 

‘ A roller,  an  inch  and  a half  wide,  is  placed  just  below  the  prominence 
)f  the  os  occipitis ; and  he  continues  it  obliquely  over  the  centre  of 
he  parietal  bone  across  the  juncture  of  the  coronal  and  sagittal  su- 
-ures,  over  the  zygomatic  arch,  under  the  chin;  and  pursuing  the  same 


382 


SPECIAL  FRACTURES. 


Barton’s  bandage  for  a fractured 
jaw. 


Fig.  306. 


Fis-  305>  direction  on  the  opposite  side  until  he  ar- 

rives at  the  back  of  the  head  ; he  then  passes 
it  obliquely  around  and  parallel  to  the  base 
of  the  lower  jaw  over  the  cbin;  and  con- 
tinues the  same  course  on  the  other  side 
until  it  ends  where  he  commenced,  and  re- 
peats.” 

Prof.  Gibson  describes  a bandage  (Fig.  306) 
for  the  same  purpose  ( Surgery , vol.  i.  246).  He 
says  that  after  the  jaw  has  been  modelled  into 
proper  shape,  and  the  mouth  firmly  closed, 
“ then  a cotton  or  linen  compress  of  moderate 
thickness,  reaching  from  the  angle  of  the 
jaw  nearly  to  the  chin,  is  placed  beneath 
and  held  by  an  assistant,  while  the  surgeon 
takes  a roller,  four  or  five  yards  long,  an  inch  and  a half  wide,  and 
passes  it  by  several  successive  turns  under  the  jaw,  up  along  the  sides 
of  the  face  and  over  the  head ; now  changing  the  course  of  the  hand- 
age,  he  causes  it  to  pass  off  at  a right  angle  from  the  perpendicular 

cast,  and  to  encircle  the  temple,  occiput, 
and  forehead  horizontally  by  several 
turns;  finally,  to  render  the  whole  more 
secure,  several  additional  horizontal 
turns  are  made  around  the  back  of  the 
neck,  under  the  ear,  along  the  base  of 
the  jaw,  over  the  point  of  the  chin.  To 
prevent  the  roller  from  slipping  or 
changing  its  position,  a short  piece  may 
be  secured  by  a pin  to  the  horizontal 
turn,  taking  care  to  fix  one  or  more 
pins  at  every  point  at  which  the  roller 
has  crossed.” 

It  should  be  borne  in  mind  that,  in 
using  any  of  the  above-described  band- 
ages in  fracture  of  the  necks  of  the  con- 
dyles,  the  horizontal  turns  around  the 
chin  and  occiput  have  a tendency  to  throw  the  lower  fragment 
upwards  and  backwards,  a position  just  the  reverse  of  that  it  ought 
to  occupy. 

To  secure  greater  firmness  in  the  bandage,  and  to  render  it  less 
liable  to  slip,  the  chin  should  be  shaved,  the  hair  cut  short,  and  a 
muslin  cap  fitted  to  the  head,  to  which  the  turns  of  the  roller  may  he 
pinned.  The  same  objects  may  also  be  obtained  by  smearing  the 
bandage  with  solutions  of  dextrine,  starch,  plaster  of  Paris,  or  other 
consolidating  material. 

In  connection  with  these  bandages  it  will  be  advantageous  to 
employ  a cap  of  softened  pasteboard,  sole-leather,  or  gutta-percha 
accurately  moulded  to  the  under  and  lateral  parts  of  the  lower  jaw. 

Two  broad  strips  of  adhesive  plaster,  one  encircling  the  top  of  the 


Gibson’s  bandage  for  a fractured  jaw. 


FRACTURE  OF  THE  INFERIOR  MAXILLARY  BONE.  383 


head  and  under  surface  of  the  chin,  and  the  other  passing  around  the 
chin  and  occiput,  will  also  make  a good  jaw-sling. 

Dr.  Hamilton  {A  Practical  Treatise  on  Fractures  and  Dislocations, 
o.  135)  says  that,  having  frequently  noticed  the  tendency  of  the  sling, 
[as  ordinarily  constructed,  and  of  Gibson’s  roller,  to  carry  the  anterior 
fragment  backwards,  he  devised,  several  years  since,  an  apparatus  in- 
tended to  obviate  this  objection.  “It  is  composed  (Fig.  307)  of  a firm 
eather  strap,  called  maxillary,  which,  passing  perpendicularly  upwards 
from  under  the  chin,  is  made  to 
buckle  upon  the  top  of  the  head,  at  a 
aoint  near  the  situation  of  the  anterior 
fontanelle.  This  strap  is  supported 
by  two  counter  straps,  called,  re- 
spectively, occipital  and  frontal ; 
nade  of  strong  linen  webbing.  One 
bf  these,  the  occipital,  is  attached  to 
he  posterior  margin  of  the  maxil- 
ary  strap,  about  half  an  inch  above 
he  ear,  and  being  carried  around 
behind  and  under  the  occiput,  it  is 
anally  buckled  to  the  maxillary 
strap  about  half  an  inch  above  the 
sar;  and  being  carried  around  be- 
lind  and  under  the  occiput,  it  is 
inally  buckled  to  the  maxillary 
trap  upon  the  opposite  side,  and  at 
, point  exactly  corresponding  to  its 
irigin.  The  frontal  stay  simply 
ntagonizes  the  occipital,  and  having 

jfcs  origin  and  termination  at  the  anterior  margins  of  the  maxillary 
trap,  it  is  buckled  horizontally  across  the  forehead,  and  just  above 
he  eyebrows.” 

“ The  maxillary  strap  is  narrow  under  the  chin,  to  avoid  pressure 
pon  the  front  of  the  neck,  but  immediately  becomes  wider,  so  as  to 
over  the  sides  of  the  inferior  maxilla  and  face ; after  which  it  gra- 
ually  diminishes  to  accommodate  the  buckle  upon  the  top  of  the 
ead.  The  anterior  margin  of  this  band,  at  the  point  corresponding 
a the  symphysis  menti,  and  for  about  two  inches  on  each  side,  is  sup- 
lied  with  thread-holes,  for  the  purpose  of  attaching  a piece  of  linen, 
/hich,  when  the  apparatus  is  in  place,  shall  cross  in  front  of  the  chin, 
nd  prevent  the  maxillary  strap  from  sliding  backwards  against  the 
'ont  of  the  neck.” 

We  shall  now  consider  a class  of  apparatus  which  contains  con- 
jivances  that  have  been  recommended  by  many  eminent  and  inge- 
ious  surgeons.  The  principle  upon  which  they  are  all  based  is  nearly 
ie  same,  namely,  clamping  the  fragments  of  the  jaw  between  two 
.arallel  forces  acting  in  opposite  directions.  Desault  seems  to  have 
irried  the  idea  into  practical  effect  in  1780.  He  employed  a sub- 
ental  splint  of  sheet-iron,  or  some  other  material,  to  which  were 
tached  sliding-hooks,  armed  with  pieces  of  cork  or  plates  of  lead,  to 


Fig.  307. 


Hamilton’s  apparatus  for  a fractured  jaw. 


384 


SPECIAL  FEACTUEES. 


catch  upon  the  crowns  of  the  teeth.  Since  that  time  surgeons  have 
made  a great  many  improvements  upon  his  clumsy  apparatus,  and 
achieved  much  success  in  the  treatment  of  fractured  jaw. 

Baron  Boyer  ( Traite  des  Maladies  Chirurgicales,  vol.  iii.  p.  131) 
recommends  that  when  the  fracture  is  oblique  and  double,  in  order  to 
prevent  deformity  of  the  jaw,  a cork  splint  grooved  in  the  form  of  a 
gutter  upon  both  its  faces,  to  accommodate  the  teeth,  should  be  placed 
between  the  dental  arches,  and  the  jaws  held  together  by  a sling  band- 
age. 

Dr.  Mutter,  of  Philadelphia,  substituted  for  the  cork  splint  a clamp 
of  silver,  as  more  cleanly,  and  not  as  liable  to  be  broken  as  the  cork  is; 
others,  still,  have  made  the  splint  of  ivory  and  certain  kinds  of  wood. 

Gutta-percha  is,  perhaps,  one  of  the  best  materials  of  which  to  make 
inter-dental  splints ; it  adapts  itself  evenly  to  the  jaws  and  teeth,  does 
not  decay,  and  with  proper  care  does  not  become  fetid  by  the  secre- 
tions of  the  mouth.  It  may  be  used  in  the  following  manner;  take 
two  pieces  of  the  gutta-percha  of  the  proper  size,  soften  them  in  water, 
and  place  one  of  them  upon  each  side  of  the  jaws,  which  being  pressed; 
together  imbed  the  gums  and  teeth  into  the  material.  After  a few 
minutes  the  gutta-percha  hardens  and  forms  an  exact  mould  of  the 
parts,  when  the  two  lateral  splints  may  be  removed,  and  properly 
trimmed  to  remove  rough  points,  or  irregular  edges;  they  are  then 
put  in  place  again,  and  the  jaws  held  together  by  the  four-tailed 
bandage  of  the  chin. 

Malgaigne  ( Traite  des  Fractures,  tom.  i.  p.  395)  describes  an  apparatus 
consisting  of  a narrow  and  thin  lamina  of  flexible  steel,  capable  ol 
adapting  itself  to  all  the  irregularities  of  the  posterior  dental  arch, 
from  its  two  extremities,  and  two  intervening  points,  equally  distant 
from  them,  four  little  metallic  pins  arise  to  the  level  of  the  crowns  oi 
the  teeth,  which  they  cross,  and  are  then  bent  qp  as  to  run  parallel  with 
their  anterior  surfaces ; the  extremities  of  the  pins  are  furnished  with 
four  little  thumb-screws  to  clamp  the  plate  against  the  back  of  the 
teeth.  To  prevent  the  screws  damaging  the  enamel  a plate  of  lead  is 
interposed  between  them. 

In  another  class  of  contrivances  a submental  splint  is  introduced  tc 
which  the  dental  splint  is  attached. 

One  of  the  first  instruments  of  this  kind  is  that  of  Butenick,  in- 
vented in  1799.  It  has  since  been  modified  by  Bush,  Hartig,  Lons 
dale,  Houzelot,  and  Jousset  (see  Atlas  of  F.  J.  Behrend,  PI.  7,  Figs.  18 
19,  20,  22). 

Several  years  ago  I contrived  an  apparatus  (Fig.  308)  which  was  usee 
successfully  in  twelve  cases  of  fractured  jaw,  more  than  half  of  whicl 
were  compound,  and  resulted  from  gunshot.  I made  a model  of  tin 
lower  jaw  with  softened  pasteboard,  and  then  spread  this  out  on  bloc! 
tin,  which  was  marked,  cut  into  shape,  and  modelled  so  as  to  fit  tin 
inferior  maxilla  exactly,  with  two  arms  extending  up  in  front  of  tin 
ears.  The  horizontal  part  was  so  rounded  as  to  fit  the  lower  edge  o 
the  bone  for  its  whole  extent,  and  projected  upwards  towards  the  alve 
olar  process  about  half  an  inch,  and  backwards  beneath  the  chin  ai 
inch  and  a quarter — this  edge  being  circular,  and  fitting  the  neel 


FRACTURE  OF  THE  INFERIOR  MAXILLARY  BONE.  885 


iabove  the  hyoid  bone.  The  splint  is  then  covered  with  buckskin,  and 
padded  here  and  there,  as  pressure  is  necessary,  at  this  or  that  point. 
Three  straps  (1,  2,  3)  are  attached  to  the  apex  of  the  arms  of  the  splint 


and  buckle  over  the  head — all  being  secured  in  the  median  line  by  a 
strap  (4).  Another  strap  (5)  passes  through  a bracket,  soldered  under 
the  body  of  the  apparatus,  and  buckles  over  the  head. 

To  the  anterior  part  of  the  apparatus  a slat  is  soldered,  through 
which  passes  a perpendicular  bar  of  stiff'  and  flattened  wire  bent  oppo- 
site the  mouth  at  a right  angle,  and  projecting  into  it.  To  the  point 
of  the  wire  a dental  splint  is  attached,  which  is  made  of  tin,  and  fitting 
the  teeth  clasps  them  on  either  side,  leaving  an  interval  between  its 
lateral  limbs,  as  seen  in  Fig.  309.  This,  the  dental  splint,  is  movable 
along  with  the  perpendicular  bar,  which  slides  through  the  chin-slat, 
and  can  be  secured  by  the  thumb-screw. 

I now  make  both  the  dental  and  submental  splints  of  gutta-percha, 
instead  of  tin.  The  advantages  of  this  apparatus  are  that  the  sub- 
dental splint  forms  an  exact  model  of  the  natural  configuration  of  the 
•jaw,  in  which  the  fragments  of  the  broken  bone  repose  in  a natural 
position,  and  shielded  from  all  lateral  pressure  from  bandages,  which 
jis  often  a cause  of  displacement;  by  means  of  the  straps  the  jaw  may 
be  pressed  in  any  desired  direction,  and  held  immovable  until  consoli- 
dation occurs ; and  lastly,  the  dental  splint  prevents  the  fragments 
overriding,  and  separates  the  jaws  sufficiently  far  to  enable  the  patient 
to  take  fluid  aliments. 

Dr.  Beans,  a dentist  of  Atlanta,  Ga.,  has  treated  over  forty  cases  of 
fractured  jaw,  with  great  success,  with  an  interdental  splint  of  vulca- 


Fig.  308. 


Fig.  309. 


The  author’s  apparatus  for  fractured  jaw. 


25 


386 


SPECIAL  FRACTURES. 


Maxillary  articulator.  1,1.  Upper  and  lower 
plates.  2,2.  Adjustable  rods.  3,3.  Adjustable 
hinge. 


Fig-  31°-  cite,  which  is  prepared  in  the  fol- 

lowing manner:  Take  impressions 
of  the  teeth  of  the  upper  and 
lower  jaws — those  of  the  latter  in 
each  fragment  separately — in  wax, 
in  the  ordinary  manner  of  dentists. 
Upon  these  make  plaster  of  Pa- 
ris casts,  which  are  to  be  placed 
in  the  position  that  the  jaws  would 
naturally  occupy  closed,  and  held 
in  a metallic  frame  called  a “ max- 
illary articulator”  (Fig.  310). 

The  casts  are  now  separated 
from  three  to  five  lines,  and  a wax 
splint  built  up  between  them,  leaving  an  interval  in  front  through 
which  aliment  may  be  introduced. 

Prepared  in  this  way,  the  model  jaws  are  removed  from  the  “articu-  - 
lator,”  and  a cast  made  of  them  in  plaster  of  Paris,  from  which  the 
wax  is  now  to  be  removed,  and  the  space  left  by  it  filled  with  India- 

rubber  softened  with  heat;  the  mould 
is  then  placed  iu  a dentist’s  “flask,” 
and  heat  applied  until  the  rubber  is 
thoroughl}'-  vulcanized.  The  splint 
is  now  finished,  and  is  to  be  removed 
from  the  flask. 

The  splint  is  applied  to  the  teeth, 
which  it  fits  very  accurately,  and  the 
jaws  are  closed  by  a submental  splint 
formed  of  a transverse  piece  of  wood, 
provided  with  a cup  at  its  centre  to 
receive  the  chin,  and  supported  by 
the  straps  in  the  way  seen  in  Fig.  311. 

For  the  first  three  or  four  weeks 
of  treatment,  a patient  with  a frac- 
tured jaw  should  take  nothing  but 
fluid  aliments,  and  after  the  removal 
of  the  apparatus  it  will  be  advisable 
for  him  to  use  soft  food  for  a few 
days,  in  order  not  to  jeopardize  the  safety  of  the  osseous  union  by 
mastication.  The  mouth  should  be  frequently  cleansed  with  tincture 
of  myrrh  or  a mixture  of  Labarraque’s  solution  in  water. 


Fig.  311. 


Bean’s  apparatus  for  fractured  jaw. 


SECTION  II. 

FRACTURES  OF  THE  BONES  OF  THE  TRUNK. 

Fracture  of  the  Hyoid  Bone. — The  hyoid  bone,  from  its  mo- 
bility, and  protected  situation  beneath  the  chin,  is  rarely  ever  fractured. 

Causes. — The  causes  of  the  injury  are  blows  upon  the  front  of  the 
neck  in  falling  against  some  hard  object;  and  pressure  with  the  fingers 
in  grasping  the  throat,  or  from  a ligature.  A case  is  reported  where 


FRACTURE  OF  THE  LARYNGEAL  CARTILAGES.  387 


the  accident  resulted  from  muscular  action,  the  head  having  been 
violently  thrown  backwards.  It  has  been  most  frequently  observed 
in  aged  persons.  The  fracture  may  affect  the  body  or  one  or  both 
cornua  of  the  hyoid. 

Symptoms. — At  the  time  of  the  infliction  of  the  injury  the  patient 
experiences  a sensation  as  if  something  had  been  crushed  at  the  upper 
part  of  the  neck,  in  which  part  and  the  jaw  severe  pain  is  felt, 
aggravated  by  the  least  motion  of  the  head  or  mouth ; articulation 
and  deglutition  are  often  impossible,  or  performed  with  the  greatest 
difficulty ; the  tongue  cannot  be  protruded  from  the  mouth ; and  there 
will  be  tumefaction  and  contusion,  often  accompanied  with  ecchymosis 
of  the  front  of  the  throat. 

If  there  is  any  displacement  of  the  fragments,  it  will  occur  inwards, 
producing  some  irregularity  in  the  contour  of  the  hyoid;  crepitus  may 
generally  be  developed,  either  by  manipulating  with  the  fingers  or  by 
efforts  of  deglutition.  Other  symptoms  have  also  been  recorded  as 
Vametimes  accompanying  this  injury,  such  as  hemorrhage  from  the 
pharynx,  in  consequence  of  the  wounding  of  its  mucous  membrane  by 
a spicula  of  bone;  suffocation,  cough,  and  expectoration. 

Prognosis. — Simple  fracture  of  the  hyoid  will  commonly  unite  in 
from  six  to  eight  weeks ; should  the  case,  however,  become  compli- 
cated with  severe  inflammation,  abscess,  or  necrosis  of  the  bone,  from 
the  violence  of  the  injury  or  the  laceration  of  the  neighboring  soft 
parts,  the  life  of  the  patient  will  be  seriously  compromised. 

Treatment. — If  there  is  displacement  of  the  fragments,  reduction 
should  be  at  once  attempted  by  pressing  them  outwards  with  the 
point  of  the  finger  introduced  into  the  pharynx.  There  is  no  tendency 
of  the  fragments  to  slip  away  from  each  other  after  they  have  been 
brought  into  their  normal  relations,  so  that  position  of  the  head  alone 
suffices  to  maintain  the  reduction.  This  should  be  one  of  moderate 
extension,  to  establish  a uniform  traction  of  the  muscles  inserted  in 
the  hyoid  bone  above  and  below.  Excessive  inflammation  must  be 
controlled  by  local  depletion  and  saturnine  and  anodyne  applications. 

Should  the  patient  not  be  able  to  swallow,  aliment  may  be  intro- 
duced into  the  stomach  with  a long  flexible  tube;  but  it  will  always 
be  better  to  deny  the  patient  everything  for  the  first  three  or  four 
days  except  what  is  absolutely  required. 

Abscess  in  the  neck  should  be  opened  at  once,  and  the  first  oppor- 
tunity sought  to  remove  any  portion  of  the  bone  that  may  have  become 
necrosed.  Should  suffocation  threaten,  tracheotomy  will,  of  course,  be 
demanded. 

Fracture  of  the  Laryngeal  Cartilages. — The  thyroid  and  cri- 
, coid  cartilages  may  be  fractured  either  separately  or  together.  As  to  the 
‘character  of  the  fracture,  it  may  be  simple,  comminuted,  or  compound. 

Causes. — The  causes  of  the  injury  are  direct  violence  inflicted  upon 
:the  part,  as  grasping  the  throat  forcibly  between  the  fingers,  falls  upon 
some  hard  projecting  ridge,  kicks  of  a horse,  and  gunshot.  During 
the  late  war  I saw  three  cases  of  fractured  thyroid  cartilage  from  the 
last-mentioned  cause,  two  of  whom  died,  and  autopsy  revealed  the 
nature  of  the  injury;  the  third  recovered. 


388 


SPECIAL  FRACTURES. 


Symptoms. — The  only  certain  symptoms  of  this  injury  are  crepitus, 
mobility  of  the  fragments,  and  deformity  of  the  larynx;  other  phe- 
nomena are,  however,  in  most  cases  present — difficult  respiration, 
whispering  voice,  or  the  voice  may  be  entirely  lost,  deglutition  painful 
or  impossible,  cough,  hemorrhage  from  the  larynx,  and  emphysema  of 
the  neck. 

Prognosis.— Fracture  of  the  laryngeal  cartilages,  even  when  simple, 
is  a serious  matter;  and  if  the  violence  inflicting  it  is  severe,  or  if 
there  should  be  displacement  of  the  fragments,  or  complications  of 
any  sort,  such  as  severe  inflammation,  &c.,  the  patient  almost  always 
loses  bis  life. 

Treatment. — The  object  of  the  practitioner  should  be  to  combat  local 
inflammation,  by  leeching  and  other  suitable  antiphlogistics.  When 
the  respiration  begins  to  be  labored,  tracheotomy  or  laryngotomy 
must  be  had  recourse  to  at  once ; it  will  be  fatal  to  the  welfare  of  the 
patient  to  delay  the  operation  too  long.  If  the  larynx  is  comminuted, 
and  the  fragments  displaced,  the  safest  plan  will  be  to  perform  laryn- 
gotomy,  and  restore  them  to  their  natural  situation. 

Fracture  of  the  Vertebras. — From  the  firm  interlocking  of  the 
vertebrae,  which  are  bound  together  by  strong  ligaments  and  covered 
by  powerful  muscles,  great  violence  is  required  to  be  inflicted  in 
order  to  fracture  them.  The  fracture  may  affect  the  body,  laminae, 
spinous  or  transverse  processes.  Its  direction  in  the  body  of  the 
vertebrae  may  be  vertical  or  oblique,  and  in  the  latter  case  it  usually 
runs  downwards  and  forwards,  causing  the  upper  fragment  to  slip  in 
a corresponding  direction. 

In  the  recorded  cases  of  this  injury  affecting  the  laminae,  the  line  of 
fracture  has  occurred  nearly  vertical,  and  upon  both  sides. 

The  transverse  processes  are  rarely  ever  broken,  and  then  always 
by  a gunshot  or  penetrating  wound  which  inflicts  grave  injury  upon 
the  surrounding  tissues  and  organs. 

Causes. — The  causes  are  blows  upon  the  line  of  the  spine,  falling 
upon  the  back  against  some  hard  and  projecting  object,  alighting 
upon  the  head,  or  buttocks,  or  even  upon  the  feet  after  being  precipi- 
tated from  a height ; and  gunshot  wounds. 

Symptoms. — The  symptoms  of  fractured  vertebrae  will  vary  accord- 
ing to  the  extent  of  the  injury,  and  its  locality.  A moderate  blow, 
especially  an  oblique  one,  upon  the  back,  may  simply  knock  off  the 
spinous  processes,  or  even  fracture  the  laminae  without  entailing  any- 
thing beyond  a moderate  amount  of  concussion  of  the  cord  which 
will  reveal  itself  by  a paralysis  of  the  lower  extremities,  disappearing 
after  the  lapse  of  some  weeks  or  months ; there  will  also  be  added 
some  derangement  of  the  secretory  action  of  the  kidneys.  In  other 
cases  not  even  these  disturbances  will  be  present. 

In  a fracture  of  the  bodies  of  the  lumbar  vertebrae  there  will  he 
paralysis,  commonly  both  of  sensation  and  motion,  of  the  legs;  and 
paralysis  of  the  bladder  and  rectum,  so  that  the  patient  cannot  pass 
the  urine,  or  relieve  his  bowels;  or  those  excretions  pass  away  from 
him  involuntarily.  With  these  symptoms  others  are  often  associated, 
as  crepitus,  mobility  of  the  fragments,  and  posterior  angular  projec- 


FBACTUEE  OF  THE  VEETEBBA3. 


889 


tion  of  the  spinous  process  of  the  fractured  vertebrae,  which  will  mate- 
rially assist  in  removing  any  doubt  in  the  mind  of  the  surgeon  as  to 
the  nature  of  the  injury. 

When  the  fracture  is  higher  up — in  the  dorsal  region — to  the  above 
enumerated  symptoms  must  be  added  derangements  of  the  stomach, 
nausea,  vomiting,  &c.,  and  tympanitic  distension  of  the  abdomen. 
And,  as  it  would  be  expected,  when  it  is  yet  higher,  but  beneath  the 
third  cervical,  the  functions  of  the  heart  and  lungs  will  also  be  dis- 
ordered; there  will  be  palpitation,  difficulty  in  respiration,  and  con- 
gestion of  the  face  from  obstruction  to  the  capillary  circulation.  The 
muscles  of  the  chest  and  those  of  the  upper  extremities  will  also  be 
paralyzed. 

A fracture  implicating  the  first  three  cervical  vertebrae,  which  are 
above  the  phrenic  nerve,  and  attended  with  displacement  of  the  frag- 
ments and  compression  of  the  cord,  must  necessarily  result  in  immedi- 
: ate  death  from  asphyxia. 

In  all  these  cases  the  urine  becomes  alkaline,  producing  chronic 
inflammation  of  the  bladder,  which  adds  greatly  to  the  sufferings  of 
the  patient. 

Should  the  person  survive  the  injury  some  time,  inflammation  arises 
in  the  cord  and  its  membranes,  and  terminates  in  effusion  and  suppu- 
1 ration. 

From  the  lowered  vitality  of  the  tissues  pressure  upon  the  sacral 
and  gluteal  regions  causes  sloughing  sores ; in  some  cases,  the  destruc- 
tion is  so  rapid  that  the  parts  almost  seem  to  melt  away. 

Diagnosis. — The  nature  and  extent  of  a fracture  of  the  spine  cannot 
always  be  made  out,  for  excepting  the  deformity,  crepitus  and  mo- 
bility of  the  fragments,  all  the  other  symptoms  may  be,  to  a greater 
or  less  extent,  the  result  of  concussion,  strains  of  the  cervical  muscles 
and  ligaments,  with  damage  to  the  cord,  and  dislocation  of  the  ver- 
tebrae, and  therefore,  in  certain  cases,  we  are  left  altogether  in  the  dark 
until  an  autopsy  reveals  the  character  of  the  injury. 

Prognosis. — The  prognosis  will  vary  with  the  seat  of  injury.  As 
we  have  already  stated  a fracture  of  the  first  three  vertebrae  accom- 
panied with  compression  of  the  cord  must  be  followed  by  death  upon 
the  spot;  in  those  cases  where  the  injury  is  seated  in  the  lower  cervical 
region  the  fatal  issue  is  commonly  delayed  from  three  to  seven  days; 
in  the  dorsal,  from  one  to  four  weeks,  and  in  the  lumbar  region,  from 
four  to  six  weeks,  or  the  patient  may  sometimes,  in  the  latter  case, 
survive  the  accident  two  or  three  years. 

Death  in  these  cases  results  from  asphyxia,  or  from  gradual  exhaus- 
tion and  nervous  irritation  often  attended  with  profuse  diarrhoea. 

Fractures  of  the  processes  of  the  vertebrae,  especially  when  un- 
associated with  compression,  are  much  more  favorable  than  those  of 
their  bodies. 

There  are  cases  of  these  injuries  recorded  where  patients  have 
recovered  to  a greater  or  less  extent,  but  they  never  regain  the  full 
enjoyment  of  all  their  bodily  functions. 

Treatment. — From  the  obscurity  in  the  diagnosis  of  fracture  of  the 
v ertebrae  the  greatest  care  and  j udgment  are  required  in  determini  ng  the 


390 


SPECIAL  FRACTURES. 


proper  manipulative  procedures  to  be  employed.  In  case  the  spinous 
processes  are  broken  and  displaced,  tbeir  position  may  be  rectified, 
and  the  reduction  maintained  by  laying  two  thick  compresses  upon 
either  side  of  the  spine  and  securing  them  with  a broad  body-bandage. 

Fracture  of  the  laminse  with  depression  has  given  rise  to  a good 
deal  of  discussion  as  to  the  propriety  of  operative  interference  to 
correct  the  displacement  of  the  fragments;  certain  cases  have  been 
successfully  treated  by  raising  the  depressed  arch,  but  experience  and 
reasoning  do  not  sustain  the  utility  of  the  operation  as  a general  mode 
of  practice.  It  will,  in  general,  be  better  to  place  the  patient  in  the 
easiest  and  most  comfortable  position  upon  a firm  mattress  or  a water- 
bed,  and  to  pursue  an  expectant  plan  of  treatment ; avoiding  every- 
thing that  would  cause  an  unnecessary  amount  of  motion  of  his  body. 
Purgatives  in  the  early  part  of  the  treatment  should  be  avoided,  and 
the  urine  must  be  removed  with  a catheter,  as  often  as  its  accumula- 
tion renders  it  necessary. 

Caution  should  be  observed  in  making  those  changes  in  the  position 
of  the  patient’s  body  required  for  the  purpose  of  changing  his  linen 
or  bedclothes;  and  in  no  case  should  he  be  placed  upon  his  face 
when  the  fracture  is  located  in  the  cervical  region  and  the  thoracic 
muscles  are  paralyzed,  for  then  the  respiration  is  performed  only  by 
the  diaphragm  and  the  abdominal  muscles,  and  to  place  the  patient 
upon  his  belly  under  these  circumstances  would  arrest  the  action  of 
these  muscles  and  thereby  cause  asphyxia. 

Those  portions  of  the  back  coming  in  contact  with  the  bed  must  be 
protected  as  much  as  possible  with  air  cushions,  and  should  bed-sores 
form  in  spite  of  these  precautions,  they  should  be  kept  scrupulously 
cleansed,  and  covered  with  a dressing  prepared  by  spreading  lead  plaster 
upon  buckskin ; after  the  sloughs  have  separated,  stimulating  applica- 
tions of  basilicon,  storax,  Labarraque’s  solution,  &c.,  will  be  useful. 

The  occurrence  of  local  inflammation  at  the  seat  of  injury  should 
be  met  by  appropriate  antiphlogistic  remedies,  leeching,  and  water- 
dressings. 

At  a later  period,  when  the  acute  symptoms  have  disappeared,  in- 
frictions of  the  extremities  with  camphorated  and  stimulating  liniments, 
containing  the  tincture  of  cantharides,  and  strychnia  internally  in 
doses  of  the  one-sixteenth  to  the  one-twelfth  of  a grain  three  times  a 
day,  will  be  serviceable  in  aiding  the  restoration  of  nervous  power. 

Fracture  of  the  Sternum. — Fracture  of  the  sternum  is  a rare 
form  of  injury  in  consequence  of  the  elasticity  of  the  thoracic  walls 
and  the  spongy  structure  of  this  bone. 

The  fracture  may  be  transverse,  oblique,  or  lougitudinal,  the  former 
being  the  most  common ; or,  again,  it  may  be  simple,  comminuted,  or 
compound.  It  may  be  located  at  any  point  of  the  bone,  but  is  most  com- 
monly encountered  in  the  neighborhood  of  the  junction  of  the  manu- 
brium with  the  middle  piece.  With  advancing  years  the  bone  becomes 
more  brittle,  and  it  is  late  in  life  that  the  fracture  is  relatively  most  fre- 
quent. 

Causes. — In  a majority  of  cases  the  fracture  results  from  direct  in- 
jury, as  the  passage  of  a heavy  wheel  over  the  chest,  or  the  fall  of  a 


FRACTURE  OF  THE  RIBS. 


391 


large  piece  of  wood  across  it.  Cases  are  reported  in  which,  it  resulted 
from  muscular  action  alone. 

Symptoms. — The  symptoms  of  this  fracture  will  consist  of  those 
arising  from  the  injury  to  the  hone  itself,  and  those  from  injury  to  the 
thoracic  viscera.  Among  the  former  will  he  noticed  displacement  of 
the  fragments,  the  lower  one  commonly  slipping  in  front  of  the  upper 
— a position  due,  according  to  Sanson,  to  the  greater  length  of  the  rihs 
attached  to  the  former  portion  ; crepitus,  which  is  more  easily  made  out 
when  the  ear  is  applied  to  the  chest,  and  pain  at  the  seat  of  fracture. 
The  symptoms  dependent  upon  damage  to  the  viscera  of  the  chest  are, 
palpitation,  difficulty  in  breathing,  cough,  expectoration  of  blood, 
emphysema,  and  inflammation  of  the  lungs  and  pleura.  A case  is  re- 
ported in  which  the  violence  was  so  great  as  to  drive  a fragment  of 
the  hone  into  the  heart  and  to  cause  death  outright. 

Prognosis. — As  this  injury  always  implies  that  great  force  has  been 
inflicted  upon  the  chest,  especially  when  it  occurs  in  young  persons, 
the  prognosis  must  in  a majority  of  cases  he  unfavorable,  and  more 
i particularly  when  the  fracture  results  from  direct  violence  and  is  com- 
plicated with  disturbances  of  the  thoracic  organs.  The  occasional 
results  of  this  injury  are  abscess  of  the  anterior  mediastinum,  and 
caries  or  necrosis  of  the  sternum. 

Treatment. — -When  there  is  an  overlapping  of  the  fragments  it  has 
been  recommended  to  effect  the  reduction  by  bending  the  body  back- 
wards over  a pillow  placed  between  the  shoulders.  Some  surgeons 
direct  the  depressed  bone  to  be  raised  by  a lever,  the  point  of  which 
is  placed  beneath  it,  or  to  sink  a screw  into  its  substance  and  use  this 
as  a handle. 

When  the  reduction  has  been  effected  a compress  is  to  be  laid  over 
the  point  of  injury  and  confined  by  a body  bandage ; the  patient  must 
be  placed  upon  his  back  with  the  thighs  drawn  up  and  supported  with 
pillows,  while  the  head  and  shoulders  are  thrown  somewhat  posteriorly. 

If  an  abscess  should  form  in  the  mediastinum  it  should  be  opened 
as  soon  as  it  points  at  the  margin  of  the  sternum.  ISTecrosis  and  caries 
of  the  bone  are  to  be  treated  in  the  manner  taught  in  general  works 
on  surgery. 

Fracture  of  the  Eibs. — Fracture  of  the  ribs,  though  not  so  un- 
common as  that  of  the  sternum,  is  yet  comparatively  infrequent.  The 
cause  of  this  is  the  elasticity  of  the  walls  of  the  chest,  which  of  course 
is  influenced  to  a greater  or  less  extent  by  the  age  of  the  subject.  The 
upper  ribs  are  so  effectually  protected  by  the  scapula  behind  and  the 
clavicle  in  front,  with  their  attached  muscles,  that  their  fracture  is  ex- 
tremely rare.  The  floating  ribs  enjoy  the  same  immunity  by  virtue 
of  their  mobility. 

The  fourth,  fifth,  sixth,  and  seventh  ribs  are  most  frequently  frac- 
tured. Its  line  is  generally  transverse,  though  it  often  is  oblique,  and 
may  even  be  somewhat  longitudinal.  Comminuted  and  compound 
fractures  are  met  with  in  some  cases,  and  in  the  latter  instance 
result  from  the  fragments  of  the  bone  penetrating  either  the  lungs  or 
skin. 

Causes. — The  causes  are  the  same  as  those  of  fracture  of  the  ster- 


392 


SPECIAL  FRACTURES. 


num — great  force  being  applied  to  the  chest  producing  the  fracture 
directly  or  by  counter-stroke;  in  the  latter  case,  as  when  the  chest  is 
violently  compressed  between  the  bumpers  of  railroad  cars,  and  the 
ribs  break  at  some  intermediate  place  between  the  points  compressed. 
Malgaigne  has  recorded  eight  cases  of  fracture  from  muscular  action. 

Symptoms. — If  there  is  displacement  of  the  fragments  of  the  broken 
ribs,  which  can  only  occur  to  any  extent  inwards  or  outwards,  angular 
deformity  will  result — the  angle  being  in  the  former  case  re-entrant  or 
depressed,  and  in  the  latter  salient ; crepitus  can  be  generally  detected 
by  directing  the  patient  to  breathe  deeply,  or  what  is  better,  cough, 
though  in  certain  cases  it  may  be  masked  by  the  swelling  of  the  parts 
or  emphysema ; preternatural  mobility  of  the  fragment  may  also  be 
made  evident  by  pressure  with  the  fingers.  Besides  these  positive 
diagnostic  signs  there  will  almost  always  be  present  other  symptoms 
indicating  injury  to  the  thoracic  viscera,  as  cough,  haemoptysis,  em- 
physema of  the  chest,  severe  pain  over  the  seat  of  injury,  or  diffused 
over  the  chest  and  aggravated  by  coughing  or  sneezing;  later,  pleu- 
ritis  or  pneumonia  may  arise. 

Prognosis. — We  can  always  expect  a favorable  issue  in  a case 
of  simple  fracture  of  the  ribs,  particularly  of  the  middle  ones,  when 
there  is  no  displacement  or  only  an  outward  projection  of  the  frag- 
ments, in  from  twenty  to  thirty  days. 

If  the  fragments  are  driven  inwards  upon  the  viscera  so  as  to  wound 
them  to  any  extent,  the  prognosis  becomes  very  serious,  for  a large 
proportion  of  such  cases  will  terminate  fatally  in  a longer  or  shorter 
time  from  the  inflammatory  complications  that  will  be  set  up.  These 
cases  are  particularly  serious  in  persons  with  a tendency  to  tubercu- 
losis, as  this  disease  is  extremely  apt  to  be  developed. 

Treatment. — The  reduction  of  the  fracture,  if  the  fragments  project 
exteriorly,  is  accomplished  by  pressing  with  the  finger  upon  the  angle 
which  they  form ; if  they  are  depressed  upon  the  lungs  and  produce 
threatening  symptoms,  their  elevation  is  indicated  either  with  the  fin- 
gers or  an  elevator  introduced  through  the  wound;  should  there  be  no 
wound,  under  circumstances  of  danger  I think  we  should  be  justified 
in  making  one.  Cases  requiring  such  treatment  must  be  exceedingly 
rare  in  civil  practice;  in  gunshot  wound  of  the  chest  I have  been  com- 
pelled, in  a number  of  cases,  to  remove  from  the  lungs  spicuke  of  bone 
an  inch  or  more  long.  The  only  bandage  required  in  these  cases  is  one 
encircling  the  chest  to  retain  the  ribs  immovable.  A compress  may  or 
may  not  be  placed  beneath  it  over  the  seat  of  injury,  according  as  there 
is  or  is  not  a tendency  to  displacement  of  the  fragments  externally. 

Should  the  displacement  be  inwards  a compress  must  be  placed 
upon  the  anterior  and  posterior  extremities  of  the  ribs,  and  confined 
by  a circular  bandage.  The  bandage  I am  in  the  habit  of  using  in 
these  cases  is  composed  of  a number  of  adhesive  strips  two  inches  wide 
and  long  enough  to  encircle  the  chest  once  and  a half,  applied  circularly 
and  imbricated.  After  the  bandage  has  been  applied  the  patient  should 
be  placed  in  the  most  comfortable  posture,  and  subsequent  inflamma- 
tory complications  combated  by  appropriate  antiphlogistic  remedies. 

Fracture  of  the  Costal  Cartilages. — Fracture  of  the  costal 


FRACTURE  OF  THE  SCAPULA. 


393 


1 cartilages  arises  from  the  same  causes  as  fracture  of  the  ribs.  The 
eighth  cartilage  is  most  frequently  affected,  and  in  all  cases  the  line 
of  fracture  is  smooth  and  transverse.  The  usual  displacement  observed 
is  the  riding  of  the  internal  fragment  over  the  outer  one,  if  the  seat  of 
fracture  is  near  the  sternum,  and  the  reverse  when  it  is  more  remote. 

Treatment. — The  same  general  line  of  treatment  must  be  observed  in 
dealing  with  a case  of  fractured  costal  cartilage  as  has  been  pointed  out 
at  page  392,  for  the  ribs.  Malgaigne  recommends,  for  the  purpose  of 
preventing  displacement  of  the  fragments,  the  application  of  a truss 
to  the  chest,  one  of  the  pads  of  which  should  press  upon  the  seat  of 
, the  fracture. 


SECTION  III. 

FRACTURES  OF  THE  BONES  OF  THE  UPPER  EXTREMITIES. 

Fracture  of  the  Scapula.— From  the  resiliency  of  the  thoracic 
walls,  the  strength,  mobility,  and  the  thickness  of  the  muscular  cover- 
ings of  the  scapula,  fracture  of  this  bone  is  rather  uncommon.  It 
may  affect  the  body,  the  neck,  the  coracoid  or  acromion  process  or 
the  inferior  angle  of  the  bone. 

1.  Fracture  of  the  acromion  process  (Fig.  312)  is  the  most  frequent 
variety  met  with  in  the  scapula.  It  may  be 
located  either  at,  behind,  or  before  the  acromio- 
clavicular articulation  : in  the  first  two  instances 
the  shoulder  losing  the  support  of  the  clavicle 
will  fall  forwards  and  downwards;  and  in  the 
latter  the  tip  of  the  acromion  will  simply  be 
depressed  upon  the  head  of  the  humerus.  The 
direction  of  the  fracture  is  generally  transverse. 

Cause.— Blows  or  falls  upon  the  shoulder  or 
elbow. 

Symptoms. — The  shoulder  being  no  longer 
supported  by  the  clavicle  approximates  to  the 
median  line,  and  is  depressed  ; the  head  of  the 
humerus  falls  into  the  axilla  as  far  as  the  cap- 
sular ligament  will  allow ; the  arm  hangs 
helplessly  by  the  patient’s  side,  who  usually 
endeavors  to  take  the  weight  of  the  limb  off  the  fractured  bone  by 
supporting  the  elbow  with  the  hand  of  the  uninjured  arm;  if  the  hand 
be  placed  upon  the  shoulder  while  the  elbow  is  forced  upwards  so  as 
to  bring  the  fragments  in  contact,  crepitus  will  be  perceptible ; and 
lastly,  in  tracing  the  spine  of  the  scapula,  that  portion  of  it  between  the 
fracture  and  clavicle  will  be  found  depressed. 

Diagnosis. — Fracture  of  the  acromion  may  be  confounded  with 
dislocation  of  the  humerus  into  the  axilla  and  fracture  of  the  clavicle 
outside  of  the  coracoid  process.  It  is  distinguished  from  the  first 
by  the  circumstances  that  in  fracture  the  deformity  may  be  made  to 
disappear  by  raising  the  elbow,  and  it  will  immediately  be  reproduced 
as  soon  as  the  support  is  removed,  and  the  acromion  will  not  present 
that  prominent  appearance  it  does  in  dislocation.  Extra-coracoid 


Fig.  312. 


394 


SPECIAL  FRACTURES. 


fracture  of  the  clavicle  will  present  little  displacement  of  the  frag- 
ments, no  alteration  in  the  rotundity  of  the  shoulder,  and  the  arm  can 
he  easily  moved  by  the  patient;  these  circumstances  will  suffice  to 
distinguish  this  injury  from  fracture  of  the  acromion  process. 

Prognosis. — -The  union  between  the  fragments  is  usually  liga- 
mentous; and  when  it  occurs  by  bone,  it  is  generally  with  some 
obliquity  of  the  outer  fragment,  which  does  not  impair  the  free  move- 
ments of  the  arm. 

Treatment. — When  the  tip  of  the  acromion  is  broken  off,  the  best 
position  for  the  arm  is  at  right  angles  to  the  body,  so  that  the  deltoid 
muscle  may  be  relaxed,  and  the  fragment  tilted  upwards.  As  this 
position  requires  the  patient  to  keep  in  a recumbent  posture,  he  will 
perhaps  decline  the  treatment ; in  that  case,  the  only  thing  the  sur- 
geon can  do  is  to  support  the  arm  in  a sling.  In  those  instances  in 
which  the  shoulder  loses  the  support  of  the  clavicle,  and  falls  down- 
wards and  forwards,  the  treatment  is  the  same  as  that  for  fractured 
clavicle,  except  that  the  axillary  cushion  may  be  of  equal  thickness, 
as  advised  by  Desault. 

2.  Fracture  of  the  coracoid  process  (Fig.  313)  is  an  extremely  rare 
form  of  injury,  and  very  difficult  of  diagnosis,  from  the  situation  of  the 

bone,  and  the  great  amount  of  violence 
necessary  to  be  inflicted  to  cause  it,  pro- 
ducing, at  the  same  time,  complications, 
such  as  fractures  of  the  clavicle,  sca- 
pula, and  humerus,  and  contusions  of 
the  soft  parts  which  effectually  shield 
it  from  detection.  The  seat  of  the 
fracture  may  be  in  any  part  of  the 
process,  or  even  extend  into  the  glenoid 
cavity. 

There  can  scarcely  be  much  dis- 
placement of  the  fragments  by  the  con- 
traction of  the  short  head  of  the  biceps, 
coraco-brachialis,  and  pectoralis  minor 
inserted  into  the  process,  unless,  at  the  same  time,  there  should  be  a 
rupture  of  the  ligaments  connecting  it  above  with  the  acromion  pro- 
cess and  clavicle.  In  this  case,  it  will  take  place  downwards. 

Symptoms. — The  patient  will  be  unable  to  adduct  the  arm,  and,  if 
there  is  not  much  swelling,  the  process  may  be  grasped  in  the  fingers, 
and  moved  so  as  to  develop  crepitus. 

Treatment. — The  indications  of  treatment  are  to  render  the  scapula 
immovable  by  a body  bandage  crossing  the  injured  shoulder,  and  to 
carry  the  elbow  well  forwards  upon  the  chest,  to  relax  those  muscles 
inserted  into  the  coracoid,  and  then  to  support  the  elbow  and  forearm 
in  a sling. 

3.  Fracture  of  the  neck  of  the  scapula  (Fig.  314)  is  also  a very  uncom- 
mon injury,  and  results  from  great  violence  inflicted  upon  the  shoulder. 
It  is  sometimes  attended  with  damage  to  the  axillary  plexus  of  nerves 
producing  paralysis,  and  injury  to  the  brachial  artery.  The  line  of  frac- 
ture passes  from  the  semilunar  notch  downwards  to  the  anterior  border 


Fig.  313. 


Fracture  of  tlie  coracoid  process. 


FRACTURE  OF  THE  SCAPULA. 


395 


of  the  scapula,  and  therefore  separates  Fig-  314- 

both  the  glenoid  fossa  and  the  cora- 
coid process  from  the  body  of  the 
bone.  The  weight  of  the  limb  carries 
the  anterior  fragment  downwards  and 
forwards. 

Symptoms. — There  will  be  a de- 
pression observed  beneath  the  acro- 
mion, giving  the  shoulder  a depressed 
appearance,  and  the  head  of  the  hu- 
merus will  be  felt  in  the  axilla ; the 
limb,  upon  measurement,  will  be  found 
longer  than  its  fellow;  crepitus  is  per- 
ceived when  the  surgeon  places  the 
tip  of  the  index  finger  of  the  left  hand 
upon  the  coracoid  process,  the  rest  of 
the  fingers  of  that  hand  embracing  the  fracture  of  the  neck  of  the  scapula, 
shoulder,  while,  with  the  right  hand, 

he  seizes  the  arm  below,  and  moves  it  in  various  directions.  The 
coracoid  itself  will  be  found  at  a greater  distance  from  the  clavicle, 
and  obeying  the  movements  of  the  humerus  rather  than,  as  it  should, 
those  of  the  scapula. 

Diagnosis. — From  dislocation  of  the  head  of  the  humerus  into  the 


axilla  this  injury  may  be  distinguished  by 


observing 


that  in  the 


Fi<?.  315. 


latter  the  depression  below  the  aero 
mion  is  not  so  deep,  and  it  may  be 
effaced,  and  the  rotundity  of  the  shoul- 
der restored  by  raising  the  elbow  ; the 
deformity  being  immediately  restored 
the  moment  the  support  is  withdrawn. 

In  fracture  of  the  neck  of  the  hu- 
merus the  arm  is  shortened,  and  the 
rounded  outline  of  the  shoulder  will 
not  be  disturbed. 

Treatment. — -The  indications  of  treat- 
ment in  this  case  are  simply  to  render 
the  scapula  immovable,  and  to  carry 
the  anterior  fragment  upwards  and 
outwards.  They  can  be  best  fulfilled 
in  the  following  manner : Place  a pad 
in  the  axilla,  with  its  base  upwards ; 
press  the  elbow  towards  the  chest  and 
a little  to  its  front;  surround  the  arm 
and  chest  with  a body  bandage ; and 
lastly,  support  the  elbow  and- forearm  in 
a sling.  Such  an  apparatus  is  seen  in 
Fig.  315;  the  sling  is  not  shown. 

4.  Fracture  of  the  body  of  the  scapula  is  produced  by  great  vio- 
lence inflicted  upon  the  chest,  and  is  usually  accompanied  with  con- 
siderable injury  to  the  soft  parts  surrounding  the  bone,  producing 


Apparatus  for  fracture  of  the  neck  of  the 
scapula. 


396 


SPECIAL  FRACTURES. 


316. 


such  an  amount  of  swelling  as  to  obscure  the  nature  of  the  injury. 
The  resulting  inflammation  is  often  so  severe  as  to  eventuate  in  necrosis 
of  the  bone,  and  impairment  of  the  functions  of  the  upper  extremity 

which  either  happens  at  once  or  succeeds 
to  the  injury. 

The  fracture  may  be  incomplete,  simple, 
or  comminuted,  and  the  line  of  its  direc- 
tion vertical,  transverse,  or  oblique.  Any 
portion  of  the  body  may  suffer,  the  spine 
or  the  portions  above  or  below  this ; but 
it  is  most  commonly  seated  below  the 
spine,  running  obliquely  from  the  anterior 
to  the  posterior  border,  as  seen  in  Fig.  316. 

There  will  not  be  much,  if  any,  dis- 
placement of  the  fragments  in  a vertical 
fracture;  but  in  a transverse  one  they 
will  be  separated,  the  levator  of  the  angle 
of  the  scapula,  and  the  rhomboid  muscles 
drawing  the  superior  fragment  upwards; 
while  the  serratus  magnus,  latissimus  dorsi 
and  teres  major  draw  the  inferior  one 
downwards. 

Symptoms. — If  the  case  is  seen  early,  by  carefully  examining  the 
borders  and  angles  of  the  scapula  any  fissure  or  separation  of  the 
bone  may  be  detected ; to  facilitate  the  examination,  the  arm  should 
be  moved  in  different  directions,  so  as  to  give  greater  prominence  to 
the  different  portions  of  the  scapula.  In  these  movements,  crepitus 
may  often  be  perceived  by  reposing  the  hand  over  the  bone.  The 
functions  of  the  arm  will  be  more  or  less  impaired,  from  the  combined 
injury  to  the  bone  and  to  the  soft  parts  surrounding  it. 

Treatment. — The  only  bandage  required  in  this  case  is  to  sling  the 
elbow  and  forearm  so  as  to  raise  the  shoulder,  that  the  muscles  inserted 
into  the  upper  fragment  of  the  scapula  may  be  relaxed,  and  the  por- 
tions of  bone  thus  brought  into  contact. 


The  ordinary  situation  of  fracture  of 
the  body  of  the  scapula. 


5.  Fracture  of  the  inferior  angle  of  the  scapula  arises  from  the  same 
causes  as  produce  the  same  injury  of  the  body  of  the  bone.  The 
nature  of  the  displacement  will  depend  upon  the  extent  of  the  muscu- 
lar insertions  into  the  angle  spared;  the  serratus  magnus  alone  will 
carry  the  fragment  forwards,  while  it,  in  conjunction  with  the  latissi- 
mus dorsi  and  the  teres  major,  will  displace  it  forwards  and  upwards, 
or  forwards  and  downwards. 

Symptoms.  — There  will  be  mobility  of  the  separated  angle,  and 
crepitus  can  always  be  produced  by  moving  the  fragments  in  opposite 
directions ; these  symptoms,  with  a knowledge  of  the  history  of  the 
case,  will  enable  the  surgeon  to  make  a correct  diagnosis. 

Treatment. — It  must  always  be  borne  in  mind  that  in  all  transverse 
fractures  of  the  scapula  great  difficulty  will  be  encountered  in  main- 
taining the  fragments  in  contact ; and  even  when  it  is  effected,  they 
will  usually  unite  awry.  It  is,  however,  consoling  to  know  that  this 
result  cannot  impair  the  usefulness  of  the  arm. 


FRACTURE  OF  THE  CLAVICLE. 


397 


In  applying  the  retentive  bandage,  authors  have  differed  consider- 
ably as  to  the  best  position  in  which  to  place  the  arm.  Some  direct 
the  elbow  to  be  carried  in  front  of  the  chest,  some  to  the  rear,  while 
others  prefer  to  retain  it  in  a line  parallel  with  the  vertical  axis  of  the 
body.  The  axillary  pad  has  been  considered  necessary  by  some,  and 
has  been  condemned  as  useless  by  others. 

; In  the  midst  of  these  conflicting  opinions,  it  would  appear  the  most 
rational  plan  to  reduce  the  fracture,  and  place  a thick  compress  along 
the  anterior  border  of  the  scapula,  then  to  surround  the  chest  with  a 
broad  bandage  passing  from  the  injured  to  the  sound  side;  the  scapula 
being  rendered  immovable,  the  arm  should  be  put  in  that  position 
which  most  completely  relaxes  the  muscles  inserted  into  the  fractured 
angle,  and  prevents  displacement.  It  may  be  that  this  requires  the 
elbow  to  be  moved  in  front  of  the  chest,  towards  the  posterior  aspect, 
or  retained  in  a vertical  direction.  When  the  object  has  been  obtained, 
the  limb  is  to  be  secured  by  a circular  bandage  embracing  the  arm 
and  chest,  while  the  forearm  and  elbow  are  supported  in  a sling. 

Desault  advises  an  axillary  pad,  with  its  apex  looking  upwards,  so 
that  the  elbow  may  be  kept  away  from  the  side.  This  plan  may  be 
adopted  or  rejected,  according  as  it  secures  the  object  in  view  or  not. 

Fracture  of  the  Clavicle. — From  the  peculiar  curved  shape, 
slenderness,  exposed  position,  and  functions  of  the  clavicle,  it  is  fre- 
quently broken.  According  to  the  statistics  of  Malgaigne,  of  2358 
cases  of  fracture  of  different  bones,  228  were  of  the  clavicle,  and  of 
these  three-fourths  were  met  with  in  the  male.  It  is  encountered  in 
all  ages,  from  infancy  to  old  age. 

The  fracture  may  be  unilateral  or  bilateral,  complete  or  incomplete, 
simple  or  comminuted  or  compound ; the  most  common  variety  being 
the  simple,  while  the  others  are  comparatively  rare.  The^line  of  frac- 
ture is  almost  invariably  more  or  less  oblique,  and  often  distinctly 
serrated.  Its  seat  is  generally  in  the  middle  third  of  the  bone,  to  the 
inner  side  of  the  coraco-clavicular  ligament,  a circumstance  which  is 
explained  by  the  fact  that  at  this  point  the  clavicle  is  more  slender 
than  elsewhere,  and  it  also  begins  here  to  change  the  direction  of  its 
curve,  so  that  an  extraneous  force  must  necessarily  act  upon  this  spot 
more  energetically  than  upon  any 
other. 

Causes. — The  most  common  cause 
of  fractured  clavicle  is  by  counter- 
stroke from  falls  upon  the  point  of 
the  shoulder ; direct  violence  also 
produces  the  same  result.  In  a few 
recorded  examples,  muscular  action 
was  the  cause. 

The  line  of  fracture  of  the  middle 
third,  in  a majority  of  cases,  is  oblique 
from  above  downwards  and  inwards, 
as  seen  in  Fig.  317 ; so  that  the  shoul- 
der, losing  the  support  of  the  clavicle, 
will  be  drawn  by  the  weight  of  the 


Fig.  317. 


Oblique  fracture  Dear  the  middle  of  the 
olaricle. 


398 


SPECIAL  FRACTURES. 


upper  extremity  downwards,  while  the  contraction  of  the  subclavius 
and  pectoralis  major  and  minor  will  give  it  a direction  forwards  and 
inwards.  The  sternal  fragment,  stayed  above  by  the  sterno-cleido- 
mastoid  muscle,  and  below  by  the  costo-clavicular  ligament,  maintains 
nearly  its  natural  position,  or  is  simply  elevated  a little;  on  the  other 
hand,  the  acromial  fragment,  following  the  movements  of  the  shoulder, 
will  overlap  the  former  upon  its  under  surface  for  half  an  inch  or 
more.  When  the  line  of  fracture  is  in  the  reverse  direction,  as  it 
sometimes  is,  the  inner  extremity  of  the  outer  fragment  will  be,  in  a 
measure,  sustained. 

Displacement  of  the  pieces  in  fracture  seated  between  the  insertion 
of  the  sterno-cleido-mastoid  and  the  attachments  .of  the  costo-clavicular 
ligament,  or  between  the  coraco-clavicular  ligaments,  cannot  take  place 
to  any  extent,  while  a fracture  outside  of  the  latter  ligaments  will  be 
attended  with  a posterior  displacement  of  the  external  fragment,  which 
will  unite  with  anterior  angular  deformity  in  spite  of  the  best  treatment. 

Symptoms. — Besides  the  apparent  deformity  caused  by  the  displace- 
ment of  the  fragments  above  described,  if  the  fingers  are  conducted 
along  the  clavicle  from  within  outwards,  they  will  suddenly  encounter 
a depression  at  the  seat  of  injury,  and  they  will  then  pass  on  to  the 
acromion  upon  a lower  plane  formed  by  the  outer  fragment ; crepitus 
will  be  perceived  when  the  pieces  of  bone  are  seized  between  the 
fingers  and  rubbed  upon  one  another,  or  better  brought  into  contact 
by  drawing  the  shoulder  outwards ; the  arm  hangs  by  the  body,  and 
is  rotated  inwards ; the  patient  inclines  his  head  to  the  damaged  side, 
and  instinctively  endeavors  to  support  the  shoulder  by  holding  the 
forearm  in  the  hand  of  the  sound  limb;  there  will  be  severe  pain 
about  the  fractured  bone,  which  is  aggravated  by  the  slightest  motions 
of  the  arm. * The  functions  of  the  upper  extremity  will  generally  be 
more  or  less  destroyed,  though  it  is  not  uncommon  to  meet  with  pa- 
tients who  can  lift  the  hand  of  the  injured  side  over  the  head. 

Contusions  should  be  sought  upon  the  point  of  the  shoulder  or 
elbow  where  the  injury  has  resulted  from  counter-stroke,  or  over  the 
clavicle  when  from  direct  injury. 

In  fractures  of  the  inner  and  outer  thirds  of  the  clavicle  deformity 
will  not  be  so  apparent,  and  therefore  these  cases  require  the  closest 
scrutiny  to  arrive  at  a correct  diagnosis. 

The  same  remark  likewise  applies  to  incomplete  fracture,  which 
generally  occurs  in  young  subjects,  and  is  characterized  by  a node-like 
swelling  at  the  seat  of  injury,  obscure  crepitus,  and  impairment  of  the 
functions  of  the  limb,  and  when  the  point  of  injury  is  pressed  upon 
with  the  tip  of  the  finger  severe  pain  is  caused. 

Prognosis. — In  simple  fracture  of  the  clavicle  by  contre-coup  the 
patient,  if  he  be  an  adult,  will  generally  do  well,  and  consolidation 
will  occur  in  about  five  weeks;  in  a child,  union  occurs  in  eighteen  or 
twenty  days.  Fractures  from  direct  blows  upon  the  clavicle  are  not 
so  favorable,  nor  are  those  which  are  comminuted,  compound,  or  com- 
plicated. 

The  subclavian  nerves  and  vessels  may  be  so  injured  as  to  cause 
paralysis  or  aneurism,  and  even  death.  A case  of  compound  commi- 


FRACTURE  OF  THE  CLAVICLE. 


399 


nuted  fracture  from  gunshot  came  under  mj  care,  in  which  the  sub- 
clavian artery  was  laid  bare  and  could  be  seen  plainly  pulsating  at 
the  bottom  of  the  wound ; the  patient  recovered  after  a tedious  illness 
and  necrosis  of  more  than  half  of  the  clavicle. 

Treatment. — The  reduction  of  the  fracture  is  very  easily  accom- 
plished by  simply  raising  the  elbow  and  pressing  the  shoulder  out- 
wards, or  by  approximating  the  shoulders  posteriorly,  the  knee  having 
been  previously  placed  between  the  scapulae.  As  a general  rule,  it 
may  be  stated  that  though  the  reduction  is  so  easy,  yet  in  those  cases 
of  complete  oblique  fracture  of  the  adult  it  will  be  impossible  to 
retain  it  by  any  apparatus  whatever,  and  union  will  therefore  occur 
with  some  degree  of  overlapping  or  deformity. 

The  indications  of  treatment  are  plain,  the  shoulder  must  be  carried 
: upwards , outwards,  and  backwards.  The  difficulties  encountered  in 
the  treatment  are  not  that  these  indications  cannot  be  fulfilled  tem- 
porarily with  suitable  bandages,  but  that,  sooner  or  later,  the  apparatus, 
of  any  description  whatever,  will  become  deranged  or  loosened  while 
the  patient  is  permitted  to  move  around  as  he  ordinarily  is  during  the 
treatment,  and  thus  the  object  in  view — immobility  of  the  clavicle — 
will  almost  certainly  be  defeated. 

To  facilitate  the  comprehension  of  the  various  contrivances  which 
[have  been  employed  in  the  treatment  of  this  injury,  we  shall  divide 
[them  into  three  classes,  according  to  their  mode  of  action : — 

1.  Apparatus  which  fulfil  one  indication  only,  namely,  maintaining 
the  shoulder  backwards. — Under  this  heading  are  to  be  placed  the 


Fig.  318. 


Fig.  319. 


Figure  of  8 bandage  for  fractured  clavicle.  Brasdor’s  apparatus  for  fractured  clavicle. 

>osterior  figure  of  8 bandage  of  the  shoulders  and  its  numerous 
aodifications. 


400 


SPECIAL  FRACTURES. 


The  figure  of  8 bandage  may  be  applied  as  seen  in  Fig.  818,  which 
shows  also  the  combination  with  it  of  an  axillary  pad  and  a circular 
bandage  for  the  purpose  of  throwing  the  shoulder  outwards.  Without 
these  modifications  the  figure  of  8 bandage  was  employed  by  Albucasis 
and  the  Arabian  school  of  surgeons.  In  France  it  found  supporters 
in  Guy  de  Chauliac,  Lanfranc,  and  A.  Pare ; J.  L.  Petit,  following  the 
example  of  Hippocrates,  enjoined  an  inter-scapulary  compress. 

Brasdor  employed  a corselet,  consisting  of  a dorsal  plate  with  lateral 
straps  for  the  shoulders,  and  steadied  by  a circular  belt  around  the 
waist,  as  seen  in  Fig.  319. 

In  Germany,  Heister  brought  forward  his  dorsal  iron  cross  with 
lateral  straps,  and  subsequently  Bruninghausen  employed  transverse 
leather  straps  connected  with  shoulder-pieces.  Hubenthal,  Brefield, 
Koppenstater,  Eicheiner,  and  Evers  invented  apparatus  based  upon 
the  same  principle  (see  Atlas  of  J.  F.  Behrend,  Plate  18). 

In  this  country  there  are  still  some  apparatus  employed  which  act 
in  the  same  manner  as  the  figure  of  8 bandage ; of  these  one  invented 

by  Dr.  Kecherly  is  seen  in  Fig. 
320.  “ The  upper  figure  exhib- 
its a front  view,  and  the  lower 
a back  view  of  the  splint,  a,  a, 
are  two  bandages  with  buckles 
attached  to  one  end  of  each; 
bb,  bb,  are  four  mortised  holes 
for  the  passage  of  the  two  band- 
ages; a,  a,  c,  a portion  of  the 
splint  padded,  to  prevent  its 
bruising  the  patient ; d,  d,  two 
loops  of  leather,  tacked  on  the 
back  of  the  splint,  for  the  pas- 
sage of  the  bandages,  where  the 
mortised  holes  are  too  far  apart  for  the  breadth  of  the  patient  from 
shoulder  to  shoulder.”  In  applying  this  apparatus  “the  end  of  the 
splint  corresponding  to  the  uninjured  side  is  to  be  pressed  close  to  the 
back  of  the  shoulder,  and  retained  so  by  drawing  the. bandage  tight, 
and  retaining  it  by  means  of  a buckle.  Previous  to  fixing  the  band- 
age, it  should  be  passed  through  two  loops  on  a small  pad,  which 
is  to  be  placed  in  the  axilla.  This  pad  is  used  for  the  purpose  of 
preventing  cutting  of  the  bandage.  After  passing  the  other  bandage 
through  two  loops,  on  a large  cuneiform  pad,  which  is  placed  in  the 
axilla  of  the  injured  side,  it  is  drawn  sufficiently  tight  and  secured  by 
the  buckle.  The  last  thing  to  be  done  is  to  place  the  handkerchief, 
doubled  in  a triangular  form,  in  such  a manner  over  the  arm,  the  front 
and  back  parts  of  the  thorax,  as  that  it  shall  draw  and  confine  the 
arm  of  the  injured  side  close  to  the  body,  give  it  support,  and  prevent 
its  falling  down.” 

2.  Apparatus  which  fulfil  two  of  the  indications,  namely,  sustaining 
the  shoulder  upwards  and  backwards. — Although  we  find  these  two 
indications  carried  in  the  spica,  scarf,  and  sling  bandages  of  Hippo- 
crates, Celsus,  Paulus  PEgineta,  and  Galen,  yet  in  modern  times 


Fis.  320. 


lb  d 


d lb 


Keclierly’s  apparatus  for  fractured  clavicle. 


FRACTURE  OF  THE  CLAVICLE. 


401 


surgeons  have  not  had  the  same  confidence  in  this  class  as  in  the 
former.  The  spica  of  Glaucius,  described  by  Galen,  is  stated  by  Vel- 
peau to  be  the  original  of  Desault’s  bandage.  L.  Richter  and  Gluge 
have  employed  the  descending  spica  of  the  arm. 

M.  Mayor  recommends  a bandage  prepared  with  a square  piece  of 
muslin  folded  in  a triangle,  the  base  of  which  was  placed  between  the 
arm  and  chest,  the  lateral  angles  extending  around  the  latter,  while  the 
depending  angle  was  carried  beneath  the  elbow,  brought  up  over  the 
forearm  and  chest,  and  its  two  parts  separated,  one  angle  passing  over 
each  shoulder  and  fastening  to  the  bandage  behind.  He  believed  that 
in  a majority  of  cases  this  bandage  would  be  efficient,  but  should  the 
deformity  persist,  he  directs  an  axillary  pad  to  be  used. 

M.  Velpeau  has  described  a bandage  which  he  speaks  of  in  the 
following  manner:  “I  have  contrived  a bandage,  by  means  of  a 
simple  roller,  which  is  adapted  both  to  sterno-clavicular  luxations,  for 
which  I had  at  first  designed  it,  and  also  to  acromio-clavicular  luxa- 
tions, fractures  of  the  clavicle,  acromion,  and  scapula,  and  even  to 
fracture  of  the  neck  of  the  humerus.  For  this  purpose  we  procure 
a bandage  of  eight  to  ten  yards  in  length.  The  head  of  this  bandage 
is  first  applied  under  the  armpit  of  the  sound  side,  or  behind,  as  with 
the  cataphrast;  it  is  then  passed  diagonally  upon  the  back  and 
shoulder  to  the  clavicle, 
upon  the  side  affected.  The 
hand  of  the  patient  is  then 
placed  upon  the  acromion 
of  the  sound  shoulder,  as  if 
embracing  this  last.  The 
elbow  thus  raised  is  brought 
in  front  of  the  point  of  the 
sternum,  and  the  affected 
shoulder  is  pushed  upward, 
backward,  and  outward,  by 
the  action  of  the  humerus, 
which  taking  its  point  d'ap- 
pui  on  the  side  of  the  chest, 
acts  like  a lever  of  the  first 
kind,  or  by  a swing-like  mo- 
tion. While  an  assistant 
keeps  the  parts  in  place,  the 
surgeon  brings  down  the 
bandage  upon  the  anterior 
surface  of  the  arm,  then 
outside  and  under  the  el- 
bow, to  bring  it  upward  and 
forward  under  the  sound 
armpit.  He  repeats  this 
three  or  four  times,  in  order 
to  have  that  number  of 
diagonal  turns,  which  obliquely  traverse  the  wounded  clavicle,  the- 
upper  part  of  the  chest,  and  the  middle  portion  of  the  arm.  In  pla.ce 
2fi 


Velpeau’s  apparatus  for  fractured  clavicle. 


402 


SPECIAL  FRACTURES. 


of  bringing  back  the  bandage  to  the  affected  shoulder,  it  is  afterwards 
passed  horizontally  upon  the  posterior  surface  of  the  thorax,  and 
brought  back  upon  the  external  surface  of  the  arm,  elbow,  or  forearm, 
in  the  form  of  circulars,  which  are  repeated  until  the  hand  which  is 
on  the  sound  shoulder  and  the  stump  of  the  affected  one  alone  remain 
uncovered.  W e finish  by  one  or  two  more  diagonals,  and  by  a similar 
number  of  horizontal  circulars. 

“ Another  bandage,  well  saturated  with  dextrine,  and  applied  exactly 
in  the  same  manner  over  the  first,  makes  a kind  of  immovable  sac,  in 
which  the  elbow  rests  without  effort,  and  without  having  the  power  to 
move  itself  either  backwards,  outwards,  or  forwards.  I have  already 
employed  it  a great  number  of  times,  and  it  has  appeared  to  me  so 
simple,  and  of  such  easy  application,  that  I do  not  hesitate  to  offer  it 
as  preferable  to  all  those  that  have  been  hitherto  proposed.” 

The  arm  may  be  very  conveniently  and  efficiently  supported  in  the 
position  recommended  by  Yelpeau  by  means  of  long  strips  of  adhesive 
plaster,  about  an  inch  and  a half  or  two  inches  wide,  passing  obliquely 
around  the  arm  and  sound  shoulder,  and  circularly  around  the  chest. 
If  it  is  deemed  necessary  an  axillary  pad  may  be  employed,  though 
generally  it  will  not  be  required.  Wattman’s  bandage  is  similar  to  this. 

A dextrine  bandage  is  also  recommended  by  Chassaignac  ( Gazette 
des  Htipitaux,  1853).  He  bends  the  arm  of  the  injured  side  at  an 
angle  of  90°,  covers  the  forearm  and  lower  half  of  the  arm  with  a 
layer  of  carded  cotton,  and  over  this  applies  a roller  soaked  in  a solu- 
tion of  dextrine.  He  now  reduces  the  fracture,  places  a compress 
over  the  lateral  and  posterior  surface  of  the  neck  of  the  sound  side 
and  another  between  the  chest  and  forearm : with  a second  dextrined 
roller  he  secures  the  arm  to  the  thorax  by  oblique  turns  running 
beneath  the  elbow  and  across  the  cervical  compress. 

Kicherand  and  B.  Bell  employed  simple  slings  to  support  the  arm. 

3.  Apparatus  which  fulfil  the  three  indications  of  supporting  the 
shoulder  backwards,  upwards,  and  outwards. — The  first  decided  pro- 
gress made  in  the  treatment  of  fractured  clavicle  was  after  the  intro- 
duction of  the  bandage  of  Desault,  which  fulfilled  the  indications 
above  mentioned  better  than  any  contrivance  that  had  been  used  up 
to  that  time.  It  is  executed  with  three  rollers  each  three  inches  wide 
and  eight  yards  long ; a wedge-shaped  cushion  three  inches  wide  at 
its  base  and  seven  inches  long,  gradually  tapering  towards  the  apex. 
In  applying  it  the  patient  is  seated  upon  a stool,  or  stands  erect,  while 
an  assistant  holds  the  injured  arm  at  right  angles  with  the  body;  the 
surgeon  places  the  wedge  in  the  axilla  with  its  base  upwards  and  has 
it  supported  close  to  the  body  until  he  has  placed  the  initial  ex- 
tremity of  the  first  roller  upon  it  and  made  three  circular  turns  around 
the  chest  and  the  wedge  to  sustain  the  latter  in  its  position,  then  the 
roller  is  conducted  in  front  of  the  thorax  over  the  sound  shoulder 
under  the  corresponding  axilla  to  appear  in  front  again,  thence  around 
to  the  back,  over  the  sound  shoulder  down  in  front  of  the  axilla, 
beneath  this  to  the  back,  when  the  roller  is  exhausted  by  circular 
turns  around  the  chest,  each  turn  overlapping  two-thirds  of  the  width 
of  its  predecessor. 


FRACTURE  OF  THE  CLAVICLE. 


403 


The  arm  is  now  brought  against  the  wedge  atfd  the  forearm  flexed 
at  right  angles,  carrying  the  elbow  a little  in  front  of  the  chest  when 
the  second  roller  is  to  be  applied  in  the  following  manner:  place  its 
initial  extremity  under  the  axilla  of  the  sound  side,  conduct  its  head 
obliquely  across  the  chest,  to  the  acromion  around  the  upper  part  of 
the  arm  and  chest,  to  the  axilla  again,  its  point  of  departure ; thus 
continue  with  the  circular  turns  until  the  arm  and  upper  half  of 
the  forearm  are  covered  in.  This  roller  answers  the  important  indica- 
tion of  forcing  the  shoulder  outwards,  the  humerus  being  used  as  a 
lever  of  the  first  kind  acting  upon  the  axillary  wedge  as  a fulcrum  ; 
hence  it  is  important  that  the  lower  turns  acting  upon  the  elbow 
; should  be  drawn  tighter  than  those  above. 

The  third  roller  serves  the  purpose  of  keeping  the  shoulder  upwards  • 
and  backwards,  and  is  applied  by  placing  its  initial  extremity  under 
the  axilla  of  the  sound  side,  then  conduct  the  cylinder  over  the  broken 
clavicle,  upon  which  a compress  must  be  placed,  down  the  posterior 
surface  of  the  arm  under  the  elbow,  and  over  the  forearm  to  the  point 
of  departure;  thence  across  the  back  obliquely  over  the  injured 
shoulder,  down  the  front  of  the  arm  and  under  the  elbow,  to  pass  ob- 
liquely across  the  chest  to  the  axilla  of  the  sound  side.  In  this  man- 
ner two  triangles  are  formed,  one  in  front  and  the  other  upon  the  pos- 
terior surface  of  the  chest ; continue  to  lay  on  these  turns  until  the 
roller  is  completed.  The  forearm  is  supported  in  a sling. 

This  bandage  becomes  loosened  and  requires  to  be  tightened  every 
five  or  six  days,  or  even  more  often  according  to  circumstances. 

It  keeps  the  patient  under  a good  deal  of  restraint,  and  the  turns  of 
the  roller  often  compress  the  thorax  painfully,  particularly  in  women. 
Cloquet  states  that  at  the  hospital  of  St.  Louis  the  third  roller  was 
omitted,  and  a sling  for  the  elbow  and  forearm  substituted.  He  fur- 
ther says  that  the  treatment  was  usually  successful,  and  the  modified 
bandage  could  easily  be  borne  by  women. 

Dupuytren,  Cruveilhier,  and  Flamant  also  employed  a bandage 
formed  of  two  rollers. 

In  order  to  remedy  the  defects  in  the  apparatus  of  Desault,  Boyer 
invented  a bandage  which  bears  his  name.  It  consists  of  an  axillary 
pad  made  of  bran,  placed  in  the  axilla  and  supported  by  two  ribbons 
fastened  to  its  superior  angles  and  tied  over  the  sound  shoulder  ; of  a 
belt  of  quilted  muslin  five  inches  wide,  to  surround  the  chest,  and 
fastened  by  three  buckles  and  a corresponding  number  of  straps ; of 
an  armlet  of  the  same  material  some  four  or  five  inches  wide,  lacing 
upon  the  arm  ; to  the  armlet  four  straps  are  attached,  two  in  front  and 
two  behind,  and  which  pass  through  corresponding  buckles  upon  the 
thoracic  belt  anteriorly  and  posteriorly.  These  straps  are  the  charac- 
teristic feature  of  Boyer’s  bandage ; with  them  the  power  is  applied  to 
throw  the  shoulder  outward.  The  forearm  is  supported  in  a sling. 

Bottcher  omits  the  armlet,  and  incloses  the  lower  part  of  the  arm 
with  the  thoracic  belt. 

Delpech’s  apparatus  is  formed  of,  1st,  a body  bandage  of  stout  mus- 
lin extending  from  the  axilla  to  a point  about  two  inches  above  the 


404 


SPECIAL  FRACTURES. 


crest  of  the  ilium,  gored  at  the  sides,  and  fastening  in  front  by  six 
buckles  and  a corresponding  number  of  straps ; to  prevent  the  band- 
age slipping  down  it  is  supported  by  shoulder-straps,  while  four  thin 
strips  of  whalebone,  sewed  in  the  muslin,  keep  it  from  working  into 
ridges ; two  loops  made  of  muslin  are  fastened  to  a point  of  the  band- 
age about  two  inches  from  its  upper  margin.  2d.  A wedge-shaped 
pad,  with  a width  at  its  base  the  diameter  of  the  arm,  and  long  enough 
to  reach  from  the  axilla  to  the  elbow ; the  pad  is  sewed  to  the  body 
bandage  so  that  its  base  exactly  occupies  the  axilla.  He  directs  the 
pad  to  be  made  of  quilted  horsehair  and  covered  first  with  a layer  of 
quilted  wool  and  then  with  a second  layer  of  carded  cotton  also 
quilted ; the  whole  to  be  nicely  covered  with  muslin.  8d.  A four- 
tailed sling  of  sheepskin  covered  with  chamois  and  well  padded  with 
cotton  at  the  centre  to  receive  the  elbow.  Each  of  the  heads  of  the 
sling  are  split  into  two  short  straps,  the  anterior  being  pierced  with 
holes  and  the  posterior  provided  with  four  buckles.  In  using  the 
apparatus  the  body  bandage  is  to  be  neatly  applied,  with  the  axillary 
pad  in  its  proper  position,  the  elbow  is  brought  to  the  side  and  engaged 
in  the  body  of  the  sling,  the  posterior  straps  are  carried  obliquely 
across  the  back,  and  engaged  in  the  loop  near  the  upper  border  of  the 
bandage,  the  two  inferior  buckles  being  conducted  over  the  shoulder, 
and  the  two  superior  under  the  axilla ; the  anterior  straps  are  also 
engaged  in  their  loop,  and  the  two  lower  tongues  engaged  in  the 
buckles  coming  over  the  shoulder,  and  the  upper  ones  into  those  ap- 
pearing beneath  the  axilla. 

From  the  descriptions  of  the  above  bandages  it  will  be  seen,  that  in 
France  in  the  treatment  of  fractured  clavicle  the  forearm  was  always 
placed  in  front  of  the  body,  and  supported  either  with  a sling  or  with 
the  turns  of  a roller. 

M.  Guillou  ( Ij  Abeille,  Medicale,  October,  1847)  reported  to  the 
Academy  of  Science  of  Paris  an  innovation  upon  this  plan  ; he  stated 
that,  for  some  years,  he  had  been  in  the  habit  of  treating  fracture 
of  the  clavicle  by  placing  the  forearm  across  the  back  of  the  chest, 
instead  of  in  front,  as  was  the  general  custom,  and  that  his  success 
justified  him  in  preferring  this  method  to  all  others. 

This  apparatus  consisted  of — 1st.  A sling  made  of  a folded  handker- 
chief of  an  appropriate  length  ; 2d,  a cravat ; 3d,  of  a body  bandage; 
4tb,  a square  cushion  of  linen,  thicker  in  its  middle  than  along  its 
margins ; 5th,  a pad  having  a ribbon  a foot  and  a half  long  attached 
to  each  side  of  its  base.  In  employing  the  bandage  place  the  wedge- 
shaped  pad  in  the  axilla  and  sustain  it  in  that  position  by  tying  the 
ribbon  attached  to  it  over  the  opposite  shoulder.  The  body  of  the 
cravat  is  put  around  the  upper  part  of  the  injured  arm  and  its  tails 
carried  behind  the  shoulder;  the  arm  is  now  brought  to  the  side  while 
the  forearm  is  thrown  across  the  back  and  supported  in  the  sling  de- 
pending from  the  neck ; the  square  compress  is  laid  between  the 
scapulae  and  sustained  in  this  position  by  the  tails  of  the  cravat,  which 
are  now  made  to  cross  it,  and  to  tie  around  the  sound  shoulder;  lastly, 
the  body  bandage  is  made  to  surround  the  chest  and  arm,  and  is  to 
be  securely  pinned. 


FRACTURE  OF  THE  CLAVICLE. 


405 


The  actions  of  the  different  parts  of  the  bandage  are  obvious ; the 
sling  raises  the  shoulder ; the  body  bandage  presses  it  outward  by 
acting  upon  the  humerus  as  a lever;  while  the  cravat  pulls  the 
, shoulder  outward,  the  square  cushion  over  which  it  passes  giving  it 
greater  leverage. 

This  apparatus  of  Guillou,  as  may  readily  be  conceived,  is  at  first 
very  irksome  to  the  patient  from  the  unusual  position  in  which  the 
arm  is  placed;  but  in  a few  days  he  will  generally  become  reconciled 
to  it.  More  serious  objections,  however,  to  the  bandage  are,  that  it 
interferes  with  a comfortable  indulgence  in  recumbency,  and  rotates 
the  arm  inwards,  so  as  to  throw  the  axillary  vessels  and  nerves  more 
directly  against  the  pad. 

Mr.  Lonsdale  ( Treatise  on  Fractures,  pp.  212,  213)  describes  a very 
simple  bandage,  seen  in  Fig.  322.  It  consists  of  a wedge-shaped  pad, 
secured  in  the  axilla  with  a roller,  upon  which  the  arm  is  to  be  laid. 
The  elbow  is  drawn  to  the  front  of  the 
chest,  and  confined  by  a few  turns  of  a 
roller  around  them,  while  the  forearm 
and  elbow  are  supported  in  a short 
sling,  as  shown  in  the  figure. 

In  America,  perhaps,  no  apparatus 
has  been  so  popular,  or  so  generally 
employed  as  that  invented  by  Dr.  Fox 
in  1828  (Fig.  323).  It  is  extremely  sim- 
ple, and  the  materials  of  which  it  is  pre- 
pared may  be  obtained  almost  every- 
where ; and  lastly,  it  answers  as  well  in 
the  treatment  of  fractured  clavicle  as 
any  of  the  bandages  yet  suggested.  As 
to  its  asserted  efficacy  in  accomplishing 
cures  without  deformity  in  all  cases  of 
this  injury,  there  is  certainly  a mis- 
take, arising,  perhaps,  from  want  of  accurate  observation.  Its  supe- 
riority over  other  sling  bandages  that  have  been  in  use  in  Europe  for 
years,  and  descriptions  of  some  of  which  we  have  already  given,  con- 
sists in  the  simplicity  of  the  materials  used  in  making  it,  and  the 
ease  with  which  it  can  be  prepared. 

The  bandage  is  composed  of,  1st,  an  axillary  wedged-shaped  pad, 
about  half  the  length  of  the  humerus,  and  with  a thickness  at  the 
base  of  two  and  a half  to  three  inches;  just  enough,  in  fact,  to  keep 
the  arm  free  from,  and  parallel  with  the  side,  and  having  attached  to 
its  base  two  long  tapes.  2d.  A padded  ring,  an  inch  or  two  thick, 
and  sufficiently  large  to  embrace  the  shoulder.  3d.  A sling,  made  of 
muslin,  and  extending  from  the  middle  of  the  humerus  to  the  wrist, 
having  attached  to  its  superior  border  one  tape,  and  two  tapes  to  its 
inferior  angles.  4th.  A sling  for  the  hand. 

In  applying  the  apparatus,  slip  the  padded  ring  over  the  sound 
shoulder;  then  place  the  pad  in  the  axilla  of  the  injured  side,  and 
support  it  in  position  by  tying  the  two  tapes  attached  to  its  base, 
to  the  padded  ring,  before  and  behind.  Now  bring  the  arm,  bent 


Fig.  322. 


Lonsdale’s  apparatus  for  fractured  clavicle. 


406 


SPECIAL  FRACTURES. 


Fox’s  apparatus  for  fractured  clavicle. 


Fig.  323.  at  right  angles,  against  the  pad; 

place  the  elbow  in  the  sling ; then 
carry  the  upper  tapes  behind  the 
chest,  and  the  other  two  in  front, 
and  tie  them  to  the  padded  ring ; 
the  hand  is  supported  in  the 
sling. 

In  Fox’s  apparatus  the  pad 
serves  the  purpose  of  a fulcrum, 
upon  which  the  humerus  is  made 
to  move  as  a lever  of  the  first 
kind,  by  applying  power  to  the 
lower  part  of  the  arm  with  the 
aid  of  the  tapes.  The  head  of  the 
humerus  may  thus  be  thrown  out- 
wards and  backwards  as  far  as 
may  be  required  to  effect  the  re- 
duction of  the  fracture,  by  simply 
varying  the  tension  of  the  tapes. 
Dr.  Hamilton  has  suggested  a desirable  modification  of  Fox’s  appa- 
ratus, to  obviate  pressure  upon  the  axillary  vessels  and  nerves.  It 
consists  in  allowing  the  arm  to  hang  vertically  beside  the  chest,  and 
in  employing  a pad  that  will  just  fill  the  axilla  when  the  elbow  is  in 
contact  with  the  body.  He  says  that  “ in  consequence  of  having 
placed  the  elbow  further  back  than  is  recommended  by  Dr.  Fox,  it 
will  be  necessary,  also,  to  vary  in  some  way  the  suspensory  tapes; 
those  coming  from  the  humeral  portion  of  the  arm-tray  must  pass  in 
equal  numbers  and  in  opposite  directions,  before  and  behind  the  hody, 
towards  the  stuffed  collar;  and  each  set  of  front  and  back  tapes, 

attached  to  the  humeral  portion  of  the  tray, 
must  be  in  pairs,  for  the  convenience  of 
tying.  I find  it  necessary,  also,  to  secure 
the  arm  to  the  body  by  two  or  three  turns 
of  a roller,  applied  always  lightly  and  with 
great  care,  so  that  its  pressure  shall  be  in 
no  degree  painful  or  uncomfortable.”  The 
proper  application  of  this  apparatus  is  seen 
in  Fig.  324. 

Another  ingenious  form  of  the  sling  hand- 
age  is  the  one  contrived  by  Dr.  E.  J.  Levis, 
of  Philadelphia(Fig.  325).  As  described  by 
him,  it  consists  of  a short,  firm  pad  in  the 
axilla,  by  which  the  shoulder  is  held  from 
the  side,  and  over  which,  as  a fulcrum,  the 
elbow  is  drawn  to  the  side.  To  the  front 
and  back  of  the  axillary  pad  are  fastened 
straps,  which  pass  directly  upwards,  and 
are  buckled  to  a wide  main  supporting 
band,  which  passes  from  the  shoulder 

Hamilton  s aPP^Ws  tor  fractured  acrosg  ^ Upper  par£  Qf  the  back,  and  OVer 


Fig.  324. 


FRACTURE  OF  THE  CLAVICLE. 


407 


the  shoulder  of  the  sound  side,  and  terminates  on  the  front  of  the 
chest.  By  this  means  the  shoulder  is  supported,  and  the  pad  im- 
movably held  high  in  the  axilla,  where  its  pressure  can  be  more 
, conveniently  borne  than  when  its  widest  part  compresses  the  brachial 
nerves  and  vessels  lower  down;  besides,  a better  leverage  is  thus 
given  to  the  arm  over  the  pad.  To  the  front  end  of  the  wide 
supporting  band  is  suspended  a sling,  by  which  the  elbow  is  sup- 
ported. On  the  back  of  the  sling,  at  a short  distance  above  the  point 

Fig.  325.  Fig.  326‘. 


of  the  elbow,  a strap  is  attached,  which  passes  obliquely  across  the 
back,  and,  coming  in  front,  is  buckled  to  the  main  supporting  band. 
The  action  of  this  strap  is  to  draw  the  elbow  to  the  side,  at  the  same 
time  supporting  it ; and  its  opposite  attachment  in  front  prevents  the 
tendency  of  the  wide  band  to  ride  upward  and  press  uncomfortably 
on  the  superficial  vessels  of  the  neck. 

By  this  combination,  united  so  as  to  form  one  continuous  piece, 
requiring  no  extra  bandage  over  it,  the  shoulder  is  firmly  held  in  the 
proper  direction  without  any  risk  of  yielding  or  slipping  of  the  ap- 
paratus, and  so  secure  that  the  most  restless  patient  cannot  dis- 
arrange it. 

In  adjusting  the  apparatus,  the  arm  is  passed  through  the  opening 
above  the  pad,  the  wide  band  thrown  across  the  opposite  shoulder,  the 
elbow  placed  in  the  sling,  and  the  long  strap  attached  to  the  back  of 
the  sling  brought  round  in  front. 

In  removing  it  from  the  patient,  it  is  only  requisite  to  loosen  the 
back  strap  which  draws  in  the  elbow,  by  unbuckling  it  at  its  front  at- 
tachment. The  other  straps  need  never  be  removed  from  the  buckles. 

The  extra  buckle,  which  will  be  noticed  at  the  front  end  of  the  wide 


408 


SPECIAL  FRACTURES. 


supporting  band,  comes  into  use  when  the  apparatus  is  reversed  for 
the  opposite  shoulder. 

The  apparatus  may  be  made  of  any  strong  material,  as  webbing, 
drilling,  or  soft  leather.  The  width  of  the  wide  band  should  be  from 
two  to  four  inches.  The  straps  which  press  upon  the  surface  were 
slightly  padded  in  the  apparatus  as  the  inventor  has  used  it,  but  this 
may  not  always  be  essential,  and  temporary  pads  might  be  placed  if 
the  pressure  should  become  anywhere  uncomfortable.  Thus  con- 
structed, it  can  be  very  speedily  prepared  at  an  emergency,  and  but- 
tons and  buttonholes  might  even  take  the  place  of  buckles. 

Probably  the  true  principle  of  treatment  in  dealing  with  fracture 
of  the  clavicle,  especially  in  its  middle  third,  is  to  act  upon  the  lower 
posterior  angle  of  the  scapula  of  the  injured  side,  and  to  some  extent 
upon  its  inner  and  posterior  margin,  by  pressing  it  upwards,  back- 
wards, and  outwards,  so  as  to  make  a lever  of  it  with  the  posterior 
surface  of  the  thorax  as  a fulcrum,  and  thus  by  restoring  the  scapula 
to  its  proper  position  at  the  same  time  to  restore  the  shoulder  and  with 
it  reduce  the  fragments  to  their  proper  apposition.  The  weight  of  the 
upper  extremity,  which  is  the  chief  cause  of  the  falling  or  drooping  of 
the  shoulder,  should  be  removed  by  a sling  upon  the  flexed  forearm 
or  by  a pillow  in  case  the  patient  is  confined  to  bed;  and  the  pressure 
on  the  scapula  may  be  effected  by  confining  the  patient  in  the  supine 
position  with  a firm,  hard  pillow  or  compress  broad  and  long  enough 
to  make  decided  pressure  on  the  whole  back  of  the  chest,  or  with  a 
compress  so  applied  and  maintained  as  to  press  especially  upon  the 
lower  and  inner  posterior  margin  of  the  scapula  of  the  injured  side. 
The  old  instrument  of  Brasdor  will  answer  this  purpose  with  slight 
modifications  and  was  probably  intended  to  do  so  by  its  author;  but 
a firmer  and  more  efficient  apparatus  has  been  proposed  by  Dr.  Ed- 
ward Hartshorne,  of  this  city.  Dr.  Hartshorne  advocated  this  princi- 
ple of  treatment  some  years  ago  at  the  Pennsylvania  Hospital,  and 
demonstrated  its  mode  of  action  upon  patients  in  the  wards  where 
he  had  long  preferred  the  confinement  of  patients  on  their  backs, 
whenever  practicable.  More  recently,  a very  similar  idea  has  been 
expressed  and  very  fully  explained  by  Dr.  John  H.  Packard,  in 
his  Mutter  lectures  before  the  Philadelphia  College  of  Physicians. 
In  a paper  (“  On  Fractures  of  the  Upper  Extremities,”  New  York  Ned. 
Journ.,  Nov.  1866,  pp.  93  to  105  inclusive)  founded  on  these  lectures, 
he  attributes  most  of  the  displacing  action  to  the  serratus  magnus  and 
pectoralis  minor,  in  addition  to  that  of  the  weight  of  the  limb,  and 
recommends  “ carrying  the  scapula  backwards”  by  “ acting  on  the  head 
of  the  humerus,  either  by  a figure  of  8 bandage,  properly  applied  and 
bearing  on  the  sound  shoulder,  the  elbow  being  carried  forwards  and 
well  supported,  or  by  a cap  of  muslin  or  linen,  so  made  as  to  embrace 
the  upper  part  of  the  arm,  and  fastened  in  the  same  way.”  Dr. 
Packard  refers  also  to  the  bandage  described  by  Dr.  J.  C.  Palmer. 
Surgeon  U.  S.  N.,  in  the  American  Journal  of  Medical  Sciences  for 
July,  1863,  as  “a  very  comfortable  contrivance  for  this  purpose.” 

Dr.  Hartshorne  is  disposed  to  regard  other  large  muscles  of  the  chest 
and  shoulders  as  more  or  less  concerned  in  aiding  that  of  the  two 


FRACTURE  OF  THE  HUMERUS. 


409 


particularly  mentioned,  especially  when  an  axillary  pad  is  used  to 
irritate  and  distend  the  armpit,  and  he  prefers  a more  decided  action 
on  the  lower  ang'le  of  the  scapula,  together  with  such  pressure  on  the 
rshoulder  as  may  press  it  backwards  without  interfering  with  the  pres- 
sure upwards  and  outwards.  The  action  of  pressure  upon  the  angle 
of  the  scapula  in  restoring  the  shoulder  and  reducing  the  fracture  by 
^extension  of  the  outer  fragment  is  very  well  shown  upon  a slender 
child  of  from  five  to  ten  years  of  age  in  whom  the  parts  are  well 
exposed  and  the  weight  of  the  limb  is  slight.  It  was  repeatedly 
shown  in  this  way  by  Dr.  Hartshorne  at  the  Pennsylvania  Hospital, 
but  although  to  some  extent  realized  and  acted  on  by  surgeons  else- 
where, it  does  not  appear  to  have  been  sufficiently  enforced.  The 
same  principle  of  treatment  was  unquestionably  carried  out,  without 
its  being  recognized,  in  the  apparatus  of  Hippocrates,  J.  L.  Petit,  and 
Gruillou,  possessing  interscapulary  pads. 

Other  forms  of  apparatus  have  been  brought  into  notice  recently, 
and  used  with  success  in  the  hands  of  their  inventors.  Among  these 
we  shall  mention  Hinton’s  “yoke  splint”  modified  by  Day,  Welch’s 
and  Bartlett’s  apparatus. 

| Fracture  of  the  Humerus. — The  humerus  may  be  broken  in 
any  part  of  its  length,  and  in  order  to  convey  a clear  idea  of  the 
nature,  causes,  and  treatment  of  this  injury  as  it  is  seated  in  different 
localities,  the  subject  requires  consideration  under  distinct  heads; 
and  first,  commencing  above,  we  shall  describe — 

1.  Fracture  through  the  Anatomical  Neck  of  the  Humerus  ( intra - 
capsular). — This  form  of  fracture  is  caused  by  direct  blows  or  falls 
upon  the  shoulder,  or  gunshot.  Its  direction  is 
such  that  that  portion  of  the  head  incrusted  with 
cartilage  is  separated  from  the  shaft  of  the  bone ; it 
does  not  generally  suffer  any  displacement,  though 
in  certain  recorded  cases  the  upper  fragment  has 
been  found  more  or  less  twisted  out  of  position, 
and  impacted  into  the  cellular  substance  of  the 
tubercles. 

Symptoms. — The  arm  will  be  found  of  the  same 
length  as  the  opposite  one,  unless  there  is  consider- 
able impaction,  in  which  case  there  will  be  some 
shortening ; the  elbow  hangs  by  the  side,  and  the 
patient  can  move  the  arm  pretty  freely.  By  press- 
ing the  humerus  towards  the  glenoid  cavity,  and 
rotating  it,  crepitus  may  be  produced ; a very  slight 
depression  will  be  observed  beneath  the  acromion. 

Treatment. — No  splints  will  be  required  in  the 
case ; the  arm  should  be  brought  to  the  side,  and 
the  forearm  supported  in  a sling.  If  the  head  of 
the  bone  becomes  necrosed,  it  must  be  removed. 

This  result  will  most  frequently  occur  in  those  cases  in  which  the  head 
of  the  bone  is  split  into  a number  of  fragments  by  lines  radiating 
from  its  centre. 

2.  Fracture  through  the  Tubercles  of  the  Humerus  (extra-capsular). — 
The  tubercles  comprehend  the  space  included  between  the  anatomical 


Fig.  327. 


Fracture  of  the  anatomi- 
cal neck. 


410 


SPECIAL  FRACTURES. 


and  surgical  necks.  This  is  a rare  form  of  fracture,  and  generally 
results  from  direct  blows  applied  to  the  shoulder. 

Symptoms. — There  will  not  usually  be  found  any  shortening,  though, 
as  in  the  previous  case,  the  fragments  may  be  impacted,  when  accurate 
measurements  with  the  tape-line  will  show  perhaps  a little ; displace- 
ment does  not  often  occur,  nor  are  the  functions  of  the  arm  impaired, 
unless  the  muscles  be  badly  bruised.  By  rotating  the  arm,  crepitus 
may  be  perceptible  to  the  hand  placed  upon  the  shoulder;  the  arm 
hangs  by  the  side  naturally,  and  there  will  be  no  depression  beneath 
the  acromion. 

Treatment. — ISTo  apparatus  is  usually  required,  except  to  place  the 
limb  by  the  side  and  support  it  in  a sling.  If  there  should  be  marked 
displacement,  however,  either  Erichsen’s  or  Welch’s  splint  may  be 
applied.  Local  inflammation  should  be  combated  by  appropriate  anti- 
phlogistic measures. 

3.  Vertical  Fracture  of  the  Head  .of  the  Humerus,  separating  the 
Greater  Tubercle  [extra-capsular). — In  this  fracture  the  greater  tubercle 
is  separated  from  the  head  of  the  humerus,  and  is  generally  somewhat 
displaced  under  the  coracoid  process.  It  is  caused  by  blows  upon  the 
front  of  the  shoulder. 

Symptoms. — The  arm  will  preserve  its  normal  length,  and,  barring 
the  effects  of  the  injury  upon  the  muscles,  it  will  possess  the  power 
of  pretty  free  motion  in  every  direction,  and  the  hand  can  be  placed 
upon  the  opposite  shoulder.  The  elbow  rests  alongside  of  the  body, 
or  perhaps  may  incline  a little  backwards.  The  tubercle  may  be  felt 
beneath  the  coracoid  process,  and  its  displacement  increases  the  antero- 
posterior diameter  of  the  upper  end  of  the  humerus.  A slight  de- 
pression may  be  observed  beneath  the  acromion,  and  if  the  tubercle 
is  fixed  with  the  fingers,  while  the  arm  is  being  rotated,  crepitus  may 
be  elicited. 

Treatment. — Combat  local  inflammation,  place  the  forearm  in  a sling, 
and  confine  the  arm  to  the  chest  with  a few  turns  of  a roller. 

4.  Fracture  of  the  Surgical  NecJc  of  the  Humerus  (Fig.  328). — The 
“surgical  neck”  of  the  humerus  embraces  the  space  extending  from 
the  base  of  the  tubercles  to  the  insertions  of  the  latissimus  dorsi  and 
pectoralis  major. 

Fracture  of  this  portion  is  the  most  common  form  of  this  kind  of 
injury  affecting  the  upper  extremity  of  the  humerus. 

It  is  met  with  in  childhood  and  adult  age ; in  the  former  case  the 
line  of  fracture  will  generally  correspond  with  that  of  the  epiphyseal 
junction. 

Causes. — The  most  frequent  cause  is  direct  injury  applied  to  the 
shoulder;  sometimes  it  results  from  falls  upon  the  elbow  and  hand, 
and  Vidal  records  a case  in  which  it  proceeded  from  muscular  action. 

Symptoms. — There  will  not  generally  be  found  a complete  displace- 
ment of  the  fragments  from  each  other,  either  in  consequence  of  the 
close  connection  of  the  long  head  of  the  biceps  to  them,  or  from  their 
being  impacted,  so  that  under  these  circumstances  no  shortening  will 
be  encountered.  Sometimes,  however,  the  reverse  occurs,  the  supra- 
spinatus,  infra-spinatus  and  teres  minor  muscles  draw  the  upper  frag- 


FRACTURE  OF  THE  HUMERUS. 


411 


nent  forwards  and  outwards,  while  the  lower  one,  obeying  the  action  of 
he  pectoralis  major,  latissimus  and  teres  major,  will  be  pulled  inwards, 
tnd  subsequently  upwards  towards  the  coracoid  process  by  the  triceps, 
piceps,  and  coraco-brachialis.  In  this  case  the  arm  will  be  more  or 
ess  shortened. 

Although  the  above  described  displacement  is  the  most  common, 
pet  there  are  recorded  examples  where  the  ends  of  both  fragments 
aave  been  thrown  inwards,  forwards  or  out- 
wards. Both  Desault  and  Dupuytren  have 
?een  the  lower  piece  projecting  outwards, 
jnder  the  deltoid,  and  the  former  surgeon 
states  that  it  has  even  pierced  that  muscle, 
and  appeared  externally. 

Where  the  fragments  are  not  separated 
crepitus  may  easily  be  developed  by  mov- 
ing the  arm  in  various  directions ; there 
will  be  some  slight  depression  below  the 
acromion,  or  at  least  some  want  of  fulness 
of  the  deltoid.  The  patient  will  be  gene- 
rally unable  to  place  his  hand  upon  the 
opposite  shoulder  unless  the  fragments  mu- 
tually sustain  each  other  by  contact  or  im- 
paction. In  this  latter  condition  of  the 
bone  its  head  will  be  found  to  move  con- 
sentaneously with  the  shaft,  while  in  a com- 
plete separation  this  will  not  be  the  case, 
the  fingers  can  feel  the  head  motionless  in 
the  glenoid  fossa  in  whatever  direction  the  arm  may  be  moved.  The 
position  of  the  arm  is  also  different  in  these  two  conditions,  hanging 
vertically  against  the  chest,  when  the  fragments  are  not  displaced,  and 
sloping  a little  outwards  with  the  elbow  away  from  the  chest  when 
they  are. 

Prognosis. — This  injury  requires  that  all  the  circumstances  of  the 
case  should  be  carefully  examined  before  a prognosis  is  given.  There 
is  often  a good  deal  of  difficulty  encountered  in  maintaining  the  frag- 
ments in  contact,  and  deformity  and  impairment  of  the  functions  of  the 
limb  result. 

It  has  been  denied  by  some  surgeons  that  bony  union  ever  occurs 
at  this  point,  but  they  say  that  the  upper  fragment  becomes  hollowed 
out  into  a cup-shaped  cavity,  which  receives  the  upper  end  of  the  lower 
one,  and  thus  forms  a sort  of  artificial  joint.  Accurate  observation 
has,  however,  in  a number  of  instances,  established  the  occurrence  of 
bony  union  after  fracture  of  the  surgical  neck. 

Treatment. — To  reduce  the  fracture  let  an  assistant  fix  the  shoulder 
while  another  assistant  makes  the  extension  by  seizing  the  middle  of 
the  forearm,  bent  at  right  angles,  in  one  hand,  and  the  wrist  in  the  other; 
i the  surgeon  will  then  endeavor  to  restore  the  displaced  fragments  to 
their  normal  position  by  pressure  with  his  fingers.  J.  L.  Petit  directs 
the  arm  to  be  held  at  right  angles  with  the  body,  while  the  extension 
is  being  made. 

In  those  cases  where  there  is  little  or  no  displacement  of  the  frag- 


Fig.  328. 


Fracture  of  the  surgical  neck  of  the 
humerus. 


412 


SPECIAL  FRACTURES. 


ments,  a simple  sling  for  the  forearm  and  a few  turns  of  a roller,  to  con- 
fine the  limb  to  the  chest,  will  be  all  that  is.  required. 

In  other  instances,  however,  where  they  are  constantly  and  obsti- 
nately disposed  to  assume  an  abnormal  position,  it  will  tax  the  surgeon’s 
skill  to  the  utmost  to  maintain  the  reduction  with  his  apparatus. 

Desault  was  in  the  habit  of  employing  a bandage  consisting  of  the 
following  pieces : 1st.  Two  long  rollers  from  two  and  a half  to  three 
inches  wide.  2d.  A wedge-shaped  pad  long  enough  to  extend  from 
the  axilla  to  the  elbow,  and  three  or  four  inches  thick  at  its  base.  3d. 
Three  splints  from  two  and  a half  to  three  inches  wide,  two  of  which 
should  be  of  the  same  length  as  the  humerus,  the  third  one  shorter. 
4th.  A sling  to  support  the  forearm,  and  sufficiently  long  so  as  not  to 
lift  the  arm.  5th.  A towel  to  inclose  the  whole  apparatus  and  chest. 

In  applying  it,  after  the  reduction  has  been  effected,  and  an  assistant 
still  keeping  up  extension,  the  surgeon  takes  one  of  the  rollers  moistened 
in  a dilute  solution  of  the  acetate  of  lead,  to  prevent  its  slipping,  con- 
fines its  initial  extremity  to  the  upper  part  of  the  forearm,  and  then, 
by  circular  and  reverse  turns,  ascends  the  arm  to  the  shoulder,  over 
which  the  roller  is  passed  to  make  two  oblique  turns  under  the  sound 
axilla ; the  roller  is  then  held  by  an  assistant. 

The  first  splint  with  its  pad  is  placed  upon  the  front  of  the  arm 
extending  between  the  bend  of  the  elbow  and  the  acromion;  the 
second  splint  upon  the  outside  of  the  arm,  reaching  from  the  external 
condyle  to  the  acromion;  and  the  third  upon  the  back  of  the  arm, 
reaching  from  the  olecranon  process  to  the  margin  of  the  axilla. 

These  splints  are  to  be  held  in  position  by  an  assistant,  while  the 
surgeon  takes  the  roller  again  and  secures  them  by  circular  turns  from 
above  downwards. 

The  pad  is  now  to  be  arranged  in  the  axilla,  and  pinned  to  the  arm- 
bandage,  care  being  taken  to  place  its  base  upwards  if  the  fragments 
are  displaced  inwards,  and  exactly  the  reverse  if  they  are  pushed  out- 
wards. 

The  arm  is  then  brought  against  the  pad  and  secured  to  the  chest 
by  the  second  roller  passing  around  the  arm  and  chest,  drawing  its 
turns  firmly  below,  and  loosely  above,  if  the  fragments  are  displaced 
inwards,  and  the  reverse  in  external  displacement. 

The  forearm  is  placed  in  the  sling,  and  the  whole  apparatus  is  enve- 
loped in  the  towel. 

The  method  of  Desault  is  a very  good  one,  and  in  several  parts  of 
Europe  is  preferred  to  any  other. 

Sir  A.  Cooper  recommends  that  a roller  be  applied  from  the  elbow 
to  the  shoulder,  splints  to  the  outer  and  inner  sides  of  the  arm,  and 
that  these  be  confined  by  another  roller.  A cushion  is  placed  in  the 
axilla  to  throw  the  head  of  the  humerus  outwards,  and  the  arm  sup- 
ported in  a long  sling,  for,  he  says,  if  the  elbow  is  raised,  the  bones 
will  overlap  and  the  union  will  be  deformed. 

Mr.  Fergusson  advises  the  bandages  seen  in  Fig.  329,  both  for  frac- 
ture of  the  surgical  neck  of  the  humerus,  and  for  that  of  the  tubercle 
and  anatomical  neck.  It  is  applied  by  drawing  down  the  lower  frag- 
ment, and  keeping  the  upper  one  in  place  by  a small  pad  in  the  axilla; 


FRACTURE  OF  THE  HUMERUS. 


413 


Apparatus  for  fracture  of  surgical 
neck  of  the  humerus. 


A 


, splint,  about  two  inches  and  a half  wide,  Fig.  329. 

eaching  from  the  acromion  to  the  elbow, 
s placed  upon  the  outside  of  the  arm  and 
:ecured  by  a roller  extending  from  the 
ingers  to  the  shoulder.  The  arm  is  then 
jrought  to  the  side  and  confined  to  the 
best  by  circular  turns : the  hand  is  sup- 
>orted  in  a sling. 

In  order  to  prevent  the  bandage  being 
leranged,  when  it  is  necessary  to  retain  it 
/.  long  time,  he  suggests  that  the  roller  be 
noistened  with  a thick  solution  of  starch 
>r  dextrine  before  its  application. 

Mr.  Erichsen,  in  managing  these  fractures 
>f  the  upper  extremity  of  the  humerus,  found 
i very  convenient  apparatus  “to  consist  of  a 
eathern  splint  about  two  feet  long  by  six 
nches  broad,  bent  upon  itself  in  the  middle, 

,o  that  one-half  of  it  may  be  applied  lengthwise  to  the  chest  and  the 
jther  half  to  the  inside  of  the  injured  arm,  the  angle  formed  by  the 
>end,  which  should  be  somewhat  obtuse,  being  well  pressed  up 
nto  the  axilla.”  In  this  way,  he  says,  the  tendency  of  the  lower 
ragment  to  displacement  inwards  is  corrected  and  the  limb  well 
teadied. 

Welch’s  shoulder-splint  (Fig.  330),  or  a splint  prepared  in  the 
ame  form,  of  leather,  gutta-percha,  felt,  or  pasteboard,  is  also 
.n  excellent  contrivance  for  maintaining  the  reduction,  and  it  is 
he  one  I generally  employ  for  this  purpose. 

In  one  case  Mr.  Tyrrell  was  obliged  to  keep  the  arm  at  right  angles 
vith  the  side,  by  means  of  a splint  shaped  like  the 
•etter  L reversed. 

Eicherand,  to  correct  the  inward  displacement  of  the 
ower  fragment,  advised  that  the  elbow  be  carried  to 
he  front  of  the  chest,  the  hand  reposing  upon  the  sound 
houlder;  it  is  bound  in  this  position  by  the  roller- 
bandage  after  the  manner  of  Velpeau’s  clavicle  appa- 
atus. 

Dupuytren  placed  a wedge-shaped  pad  in  the  axilla 
vith  its  base  downwards  and  confined  the  arm  to  the 
ide  with  a roller  bandage. 

5.  Fracture  of  the  Body  of  the  Humerus. — The  body 
f the  humerus  includes  the  space  between  the  surgical 
eck  and  the  condyles. 

Causes. — The  causes  of  this  fracture  are  direct  vio- 
ence,  counter-stroke  from  falls  upon  the  elbow  or  hand, 
nd  muscular  action. 

The  nature  of  the  displacement  will  depend  upon 
ie  seat  of  the  injury ; if  it  is  above  the  insertion  of 
ie  deltoid,  the  action  of  this  muscle  will  draw  the 
)wer  fragment  upwards  and  outwards,  while  the  upper  piece  will 


330. 


Welch’s  shoulder- 
splint. 


414 


SPECIAL  FRACTURES. 


be  depressed  towards  the  chest  by  the  latissimus  dorsi  and  pectoralis 
major. 

When  the  fracture  is  below  this  point,  the  deltoid  will  draw  the 
upper  fragment  outwards  and  a little  forwards,  and  the  lower  one  will 
be  lifted  by  the  biceps  and  triceps  upwards  and  inwards,  though  in 
most  cases  the  weight  of  the  limb  below  will  prevent  the  latter  dis- 
placement in  a great  measure. 

From  the  close  connection  of  the  triceps  and  brachialis  anticus  with 
the  lower  part  of  the  humerus,  a fracture  in  this  portion  will  determine 
very  little  derangement  of  the  fragments. 

Symptoms. — Crepitus  may  be  easily  developed  by  moving  the  frag- 
ments ; the  limb  will  generally  be  shortened,  the  cases  in  which  it  will 
not  be  observed  are  those  where  the  line  of  fracture  is  transverse; 
there  will  be  preternatural  mobility;  and  the  patient  will  be  unable 
to  use  the  limb. 

This  fracture  usually  unites  in  six  or  seven  weeks,  with  an  average 
shortening  of  three-fourths  of  an  inch,  if  it  is  an  oblique  one. 

Treatment. — To  accomplish  the  reduction  let  an  assistant  fix  the 
shoulder  by  grasping  it  in  his  hands;  the  surgeon  then  takes  hold  of 
the  arm  and  makes  extension  until  the  object  is  accomplished. 

The  ordinary  retentive  bandage  for  fracture  of  the  body  of  the 
humerus  is  applied  in  the  following  manner : with  a roller  envelop 
the  arm  moderately  from  the  fingers  to  the  shoulder,  making  four  or 
five  circular  turns  at  the  point  of  fracture ; take  four  padded  splints 
of  different  lengths,  one  of  which  is  to  be  placed  upon  the  outside  of 
the  arm  reaching  from  the  acromion  to  the  outer  condyle,  a second 
upon  the  inuer  side  extending  between  the  axilla  and  inner  condyle, 
a third  upon  the  posterior  surface,  and  the  last  otie  upon  the  anterior. 
These  splints  are  to  be  held  by  an  assistant  while  the  surgeon  secures 
them  either  with  the  roller-bandage  or  with  three  strips  of  bandage 
tied  around  them  at  equal  intervals. 

The  inner  splint  is,  to  some  extent,  objectionable,  as  it  may  exer- 
cise injurious  pressure  upon  the  axillary  vessels  and  nerves.  It  can 
be  easily  discarded  without  impairing  the  efficiency  of  the  apparatus, 
the  support  given  to  the  bone  by  it,  being  sustained  by  moving  the 
anterior  and  posterior  splints  near  each  other. 

It  has  been  suggested,  to  obviate  this  objection,  to  substitute  for  the 
inner  splint  an  axillary  pad;  but  this  does  not  accomplish  the  pur- 
pose, as  it  too  will  exert  pressure  upon  those  parts. 

Grooved  splints  are  much  more  efficient  than  flat  ones,  and  should 
always  be  used  if  they  are  attainable,  inasmuch  as  they  afford  a more 
uniform  support  to  the  surface  of  the  arm. 

Mayor’s  apparatus  consists  of  a wire  frame  extending  from  the 
shoulder  to  the  elbow,  and  embracing  two-thirds  of  the  circumference 
of  the  arm.  This  splint  is  to  be  padded  with  cotton  batting,  and 
secured  to  the  limb  with  three  pieces  of  bandage  tied  around  them  at 
equal  intervals. 

Equally  as  efficient  a splint  may  be  made,  in  the  same  shape,  of 
pasteboard,  sole-leather,  gutta-percha,  wood,  or  tin. 

If  the  fracture  is  compound,  that  portion  of  the  splint  correspond- 


FRACTURE  OF  THE  HUMERUS. 


415 


Fig.  331. 


lug  with  the  injury  may  he  removed,  if  it  is  required,  to  facilitate  the 
application  of  the  necessary  dressings. 

If  the  patient  is  confined  to  bed,  permanent  extension  may  be  em- 
ployed; if  the  ordinary  apparatus  fails,  by  adhesive  strips  attached  to 
the  limb  and  connected  with  cords  which  may  be  fastened  to  the  head 
and  foot  of  the  bed. 

Mr.  Lonsdale  used  an  apparatus  for  making  extension,  “consisting 
of  a thin  bar  of  iron,  about  an  inch  and  a half  wide,  and  long  enough 
to  extend  from  the  axilla  to  the  elbow,  marked  B in 
the  wood-cut  (Fig.  331).  The  lower  end  of  the  bar 
curves  upwards  underneath  the  elbow,  so  as  to  allow 
of  this  part  of  the  limb  fitting  into  it  at  C.  This 
curve  ends  in  a hook,  E,  for  the  attachment  of  a 
oandage ; and  on  the  splint  opposite  to  this  hook  is 
a small  bar,  placed  across  the  perpendicular,  also 
for  the  attachment  of  a bandage.  To  the  upper  ex- 
tremity of  the  splint  a crutch  is  adapted,  A,  which 
fits  underneath  the  axilla,  and  is  movable  up  and 
iown,  being  confined  at  pleasure  by  means  of  a small 
screw  placed  at  the  side  of  the  vertical  bar.”  It  is 
placed  upon  the  inner  side  of  the  arm,  with  the 
icrutch  in  the  axilla,  and  the  elbow  in  its  lower 
Curved  end,  in  which  it  is  secured  by  a bandage 
passing  about  the  hook  and  the  little  cross-piece 
’opposite  it. 

The  apparatus  of  Hind  is  superior  to  the  instru- 
ment of  Lonsdale,  inasmuch  as  it  supports  the  limb 
more  effectually.  It  is  composed  of  a metallic  splint 
;o  be  placed  upon  the  inner  side  of  the  arm,  divided 
into  two  sections  moving  in  opposite  directions  by  a 
screw,  and  supporting  at  its  upper  extremity  a crutch  to  rest  in  the 
ixilla.  The  splint  is  movably  articulated  to  a padded  metallic  gutter, 
,o  inclose  the  forearm.  By  this  arrangement  the  arm  can  be  sustained 
it  any  angle  of  flexion.  The  apparatus  is  secured  to  the  limb  by  four 
straps — two  above,  to  encircle  the  arm ; and  two  below,  for  the  forearm. 

The  “immovable  apparatus,”  prepared  with  plaster,  pasteboard,  or 
starched  bandages,  and  already  fully  described,  will  also,  in  some  of 
hese  cases  of  fracture,  be  found  to  be  an  exceedingly  elegant  and 
fificient  contrivance. 


Lonsdale’s  apparatus 
for  fracture  of  the  hu- 


6.  Fracture  of  the  Humerus  througJi  the  Base  of  the  Condyles. — This 
njury  is  produced  by  falls  upon  the  elbow.  The  position  of  this 
racture,  which  is  generally  oblique,  is  seen  in  Fig.  332. 

Symptoms. — The  arm  will  be  found  semi-flexed  and  shortened ; there 
■ s a preternatural  mobility  just  above  the  elbow;  the  olecranon  pro- 
ects  posteriorly ; a hard  tumor  is  formed  in  the  bend  of  the  elbow  by 
he  projection  of  the  lower  end  of  the  upper  fragment ; there  will  be 
m increase  in  the  antero-posterior  diameter  of  the  elbow-joint ; and 
/repitus  may  be  easily  developed  by  moving  the  fragments. 

Diagnosis. — From  the  proximity  of  this  fracture  to  the  joint,  it  may 
>e  confounded  with  dislocation  of  both  bones  backwards.  The  main 


416 


SPECIAL  FRACTURES. 


Fig.  332. 


features  of  the  two  injuries  will  be  found  contrasted  in  the  following 
table : — 


Fracture. 

Falls  upon  the  elbow. 

Preternatural. 

Present. 

Easy  by  extension,  bones  be- 
coming again  displaced 
when  it  is  removed. 


Diminished. 


Unchanged.  | 

Prominence  of  the  elbow  in-  1 
creased  by  extension  of  the  i 
forearm.  J 

Tumor  formed  by  lower  end 
of  upper  fragment  in  the  j 
bend  of  the  arm  not  large,  }■ 
and  above  the  fold  of  the  j 
elbow.  J 


Cause. 

Mobility. 

Crepitus. 

Reduction. 


Dislocation. 

Falls  upon  the  palms  of  the 
hands  with  arms  extended. 

Much  decreased. 

Absent. 

More  difficult,  hones  not  dis- 
posed to  become  displaced 
after  reduction. 


V N 

”1 


Not  diminished. 


Length  of  humerus,  ~] 
measured  between 
condyle  and  acro- 
mion. 

Relation  of  apex  of  1 

the  olecranon  with  V It  is  much  above. 
the  condyles.  ) 

Prominence  of  the  el-  f Pr0minelDCf  °f  the  elbow  di- 
> J « minished  by  extension  of 

I the  forearm. 


Tumor  in  bend  of  the 
elbow. 


Tumor  very  prominent,  and 
below  the  fold  of  the  elbow. 


Prognosis. — Union  occurs  in  from  seven  to  eight  weeks,  commonly 
with  some  shortening,  from  a half  to  three-quarters  of  an  inch.  After 


Fig.  333. 


Physick  s elbow-splints. 


the  removal  of  the  apparatus,  the 
functions  of  the  elbow  will  not  be 
fully  restored  until  after  the  lapse 
of  several  months. 

Treatment. — The  reduction  of 
the  fracture  is  effected  by  exten- 
sion and  counter-extension  in  the 
manner  pointed  out  above. 

For  the  purpose  of  maintaining 
the  fragments  immovable,  the  late 
Dr.  Physick  recommended  two  an- 
gular splints  (Fig.  363),  whichkeep 
the  forearm  flexed  at  right  angles. 


FRACTURE  OF  THE  HUMERUS. 


417 


In  applying  the  apparatus,  the  fracture  is  to  be  reduced,  and  a 
roller  put  on  the  limb  from  the  hand  to  the  shoulder;  the  splints  are 
padded,  laid  on  the  limb,  and  secured  in  position  by  the  roller  passing 
n-ound  them  from  above  downwards. 

These  splints  may  be  made  of  wood  or  pasteboard,  and  should  be 
m inch  and  a half  wide,  the  part  applied  to  the  arm  extending  from 
pear  the  shoulder  to  the  elbow,  and  that  to  the  forearm  from  the  elbow 
po  the  ends  of  the  fingers,  so  as  to  prevent  any  motion  in  the  hand  ; 
a handkerchief,  passing  around  the  neck  as  a sling,  supports  the  weight 
pf  the  forearm. 

Sir  A.  Cooper,  in  treating  this  injury,  directs  the  arm  to  be  bent  and 
irawn  forwards  to  effect  replace- 
ment ; “ and  then  a roller  should  FlS-  334- 

be  applied  while  it  is  in  the  bent 
position.  The  best  splint  for  it 
is  one  formed  at  right  angles,  the 
upper  portion  of  which  is  to  be 
placed  behind  the  upper  arm,  and 
the  lower  portion  under  the  fore- 
urn;  a splint  must  also  be  placed 
upon  the  forepart  of  the  upper 
urn,  and  straps  to  confine  both  ; 
and  the  arm  kept  in  a bent  po- 
sition by  a sling  (Fig.  334). 

“ In  a fortnight,  if  the  patient 
oe  young,  passive  motion  may 
ue  gently  begun  to  prevent  the 
)ccurrence  of  anchylosis;  and  in  the  adult,  at  the  end  of  three  weeks, 
i similar  treatment  is  to  be  pursued.” 

Mr.  Fergusson  advises  that  a piece  of  pasteboard,  gutta-percha, 
>r  strong  bend-leather,  of  the  shape  similar  to  that  shown  in  Fig. 
>35,  should  be  applied  on  one 

surface  of  the  elbow,  another  of  Fig-  335. 

t like  kind  on  the  opposite,  and  ^ 

)oth  should  be  retained  with  a 
oandage,  which  should  extend  as 
sere  exhibited,  from  the  hand  to 
he  middle  of  the  arm.  The 
:plint  for  the  inner  side  should 
lave  a round  hole  or  deep  hollow 
opposite  the  condyle,  so  that  it 
nay  fit  all  the  better  without  in- 
urious  pressure.  Sometimes,  if 
>andages  are  thus  applied,  it 
vill  be  found  that  the  fingers 
lecome  oedematous,  when  they 
Iso  may  be  enveloped  in  narrow 
oilers. 

Dr.  Hamilton  prepares  an  ap- 
iaratus  for  this  injury  by  moulding  to  the  shoulder,  arm,  and  forearm, 
27 


Sir  A.  Cooper’s  splint  for  fracture  of  humerus. 


Fergusson’s  mode  of  treating  fracture  above  the 
condyles. 


418 


SPECIAL  FPvACTUB.es. 


F,S-  336-  as  far  as  the  base  of  the  fingers, 

a sheet  of  gutta-percha,  as  seen 
in  Fig.  836. 

In  applying  the  splint,  pad  it 
neatly  with  cotton-batting  so  as 
to  make  the  pressure  uniform 
everywhere,  put  it  on  the  limb, 
and  secure  it  in  position  by  a 
roller  bandage. 

As  early  as  the  eighth  day  he 
directs  that  the  arm  be  removed 
from  the  splint  and  gentle  pas- 
sive motion  imposed  upon  the 
joint,  to  prevent  anchylosis;  this 
must  be  repeated  as  often  as 
every  second  or  third  day. 

In  the  construction  of  the  fore- 
going apparatus,  the  arm  and 
forearm  splints  are  immovably 
connected  at  the  elbow.  There 
are  others  in  which  provision  is 
made  for  obtaining  motion  at 
the  elbow-joint.  Of  these  the 
one  I prefer  to  all  others,  and  which,  in  my  opinion,  possesses  all  the 
advantages  derivable  for  an  elbow  splint  is  that  of  Dr.  Bond.  It  con- 
sists of  two  metallic  gutters,  one  for  the  arm  and  the  other  for  the 
forearm,  connected  together  upon  one  side  by  a lateral  bar  of  iron 
jointed  at  the  elbow  ; the  motions  of  the  joint  being  controlled  by  a 
screw. 

As  seen  in  Fig.  337,  the  bar  is  connected  with  the  gutters  in  such  a 


Hamilton’s  elbow  splint. 


Fig.  337* 


Bond's  elbow  splint. 


manner  that  the  former  may  be  removed  at  pleasure,  and  adapted  tc 
gutters  of  any  size. 

Iu  using  the  apparatus,  the  splint  must  be  padded  with  cotton- 


FRACTURE  OF  THE  HUMERUS. 


419 


Fig.  338. 


batting,  and  the  arm  laid  upon  it ; then  apply  a roller  bandage  from 
below  upwards. 

At  the  end  of  seven  or  eight  days,  by  simply  loosening  the  screw 
it  the  elbow,  passive  motion  may  be  imposed  upon  the  joint  without 
listurbing  the  apparatus  in  the  least. 

The  apparatus  of  Welch  (Fig.  338)  is  made  in  a similar  manner  to 
hat  of  Bond’s,  gutta-percha  being  substituted  for  metal  in  making 
he  splints.  The  metallic  joints 
nay  be  removed  at  will,  and 
out  upon  other  splints. 

Dr.  Kirkbride',s  elbow  splint 
Consists  of  two  short  splints 
Connected  at  the  elbow  by  a 
linge.  The  arrangement  for 
ihecking  the  joint  movement 
s formed  of  a swivel  eye  pass- 
ng  through  the  top  of  the 
.splint,  riveted  upon  its  pos- 
terior edge,  and  a row  of  me- 
tallic eyes,  two  inches  apart, 
between  which  there  are  series 
>f  small  holes  in  the  wood  upon 
ts  anterior  edge ; by  means  of 
i wire  connected  with  the 
swivel  eye  above,  and  hooked 
n the  eyes  and  holes  below, 
he  arm  may  be  bent  to  any 

single  (Fig.  339).  Welch’s  elbow  splint. 


Fig.  339. 


KiTklrride’s  elbow  splint. 


This  splint  is  to  be  padded  and  applied  upon  either  the  inner  or 
uter  side  of  the  limb  with  a roller  bandage. 

The  splints  of  Bose  and  Day  are  constructed  in  the  manner  seen  in 
jigs.  340  and  341.  They  are  made  of  wood,  and  carved  in  the  shape 
f the  surface  of  the  limb ; they  are  much  less  convenient  and  efficient 
ban  the  apparatus  described  previously. 

In  compound  fracture  near  the  elbow  I have,  in  several  instances, 
sed  the  apparatus  recommended  by  Mayo  with  advantage  (Fig.  342). 
t consists  of  “ two  splints  joined  together  by  two  small  bars  so  as  to 


420 


SPECIAL  FRACTURES. 


Fig.  340. 


Fig.  341. 


Hose’s  splint. 


Day’s  splint. 


leave  a space  between  them  for  the  elbow  to  fit  into.  One  of  the 
splints,  B,  seen  in  the  wood-cut,  is  made  for  the  back  part  of  the  arm 


to  lie  upon,  while  the  other,  C,  is  for  the  forearm;  the  second  splint 
terminates  in  a horizontal  portion,  D,  for  the  hand  to  rest  upon ; the 
intervening  space,  A,  is  formed  by  the  two  lateral  bars,  which  are 
slightly  curved  outwards,  to  prevent  pressure  upon  the  joint. 

7.  Fracture  through  the  Lower  Epiphysis  of  the  Radius. — Dr.  Robert 
Smith,  of  Dublin,  describes  a fracture  occurring  in  young  persons  be- 
fore the  ossification  of  the  lower  epiphyseal  centres  to  the  shaft  of  the 
humerus  has  taken  place,  which  differs  from  the  supra-condyloid  frac- 
ture in  that  the  line  of  separation  runs  below  the  condyles,  which  pro- 
perly belong  to  the  diaphysis  of  the  bone. 

He  remarks  that  “ the  symptoms  which  belong  to  it  in  common  with 
fracture  above  the  condyles  are  the  following:  Shortening,  crepitus, 
the  removal  of  the  deformity  by  extension,  and  its  tendency  to  recur 
when  the  extending  force  is  relaxed ; the  presence  of  an  osseous  tumor 
in  frout  of  the  joint;  the  increase  in  the  antero-posterior  direction  of 
the  elbow. 

“ It  differs  from  supra-condyloid  fracture  in  the  greater  trarisverse 
breadth  and  regular  convex  outline  of  the  anterior  tumor:  in  the  ex- 
istence of  two  tumors  posteriorly ; in  the  loss  of  the  normal  relation 
of  the  olecranon  to  the  condyles. 

“ It  resembles  dislocation  of  both  bones  of  the  forearm  backwards, 
in  the  following  particulars  : — 

“ The  transverse  diameter  of  the  anterior  tumor  is  the  same  in  each 


Fig.  342. 


Mayo’s  apparatus  for  fracture. 


FRACTURE  OF  THE  HUMERUS. 


421 


Fig.  343. 


Fracture  at  tlie  base  of  and 
between  the  condyles. 


;ase ; so  also  is  the  antero-posterior  breadth  of  the  elbow ; and  in  both 
he  olecranon  ascends  above  the  condyles,  the  limb  is  shortened,  and 
,wo  osseous  prominences  can  be  distinguished  posteriorly.  It  differs, 
however,  from  luxation  in  the  existence  of  crepitus,  the  tendency  of 
he  deformity  to  recur,  in  the  anterior  tumor  being  destitute  of  trochlea 
jmd  capitulum,  and  in  the  circumstance  of  the  two  posterior  tumors 
ueing  nearly  upon  the  same  level.” 

8.  Fracture  through  the  Base  of  the  Condyles  with  a Fracture  running 
between  them  into  the  Joint. — This  variety  of  fracture  is  seen  in  Fig. 
148.  It  is  caused  by  falls  and  blows  upon  the 
elbow. 

Symptoms. — The  arm  will  be  shortened ; the 
elbow  increased  in  width ; ulna  and  radius  dis- 
placed backwards  and  upwards  ; preternatural 
mobility ; and  crepitus  may  be  elicited  when 
the  ulna  is  drawn  down  into  place,  and  the  con- 
lyles  are  rubbed  against  each  other. 

Treatment. — Whatever  method  of  treatment 
Inay  be  pursued  in  this  fracture,  anchylosis  will 
be  almost  sure  to  follow. 

I have  an  interesting  specimen  of  this  frac- 
ure  which  I obtained  from  an  arm  amputated 
Due  year  after  the  injury.  The  joint  was  anchy- 
iosed,  and  there  was  a complete  abolition  of 
sensation  and  motion  below  the  point  injured. 

The  line  of  fracture  is  exactly  transverse ; the  external  condyle  with 
he  portion  of  trochlea  attached  is  displaced  backwards  so  that  its  an- 
terior border  corresponds  with  a line  running  across  the  middle  of 
he  lower  surface  of  the  upper  fragment.  The  internal  condyle,  with 
hat  part  of  the  trochlea  connected  with  it,  is  displaced  upwards,  its 
external  edge  lying  beneath  the  inner  edge  of  the  external  fragment, 
ind  united  to  the  shaft  of  the  humerus. 

The  surgeon  ought  to  replace  the  fragments  as  well  as  he  can  by 
'laving  the  limb  extended,  while  with  the  fingers 
ie  presses  them  into  their  natural  position.  One 
pf  the  elbow  splints  above  described  may  then  be 
applied. 

Desault  recommends  an  apparatus  which  con- 
sists of  two  angular  splints,  one  for  each  side  of 
he  arm,  and  two  others  for  its  anterior  and  pos- 
terior surfaces.  These  are  to  be  accurately 
noulded  to  the  elbow,  then  padded  and  secured 
to  the  arm  with  a roller  bandage. 

9.  Fracture  through  the  External  Condyle— In 
’racture  of  the  external  condyle  the  line  of  sepa- 
ration passes  from  the  external  condjdoid  ridge 
beyond  the  capsular  ligament  downwards  and 
nwards  into  the  joint,  as  seen  in  Fig.  344. 

This  injury  is  generally  met  with  in  children, 
md  results  from  blows  or  falls  upon  the  elbow. 


Fig.  344. 


Fracture  of  the  external 
condyle. 


422 


SPECIAL  FRACTURES. 


Fig.  345. 


There  will  not  usually  be  found  much  displacement  of  the  fragment, 
in  consequence  of  the  support  given  to  it  by  the  surrounding  muscular 
fibres;  there  are  cases,  however,  in  which  the  condyle  is  displaced 
backwards,  carrying  along  with  it  the  head  of  the  radius. 

Symptoms. — Pain  in  the  movements  of  flexion  and  extension;  pro- 
minence of  the  fractured  condyle;  crepitus  developed  by  rotating  the 
forearm;  and  when  the  forearm  is  extended,  it  is  sometimes  deflected 
towards  its  radial  margin. 

Treatment. — Place  the  forearm  at  right  angles  with  the  arm,  and 
apply  one  of  the  rectangular  splints  already  described.  It  may  be 
necessary,  in  rare  cases,  in  order  to  keep  the  condyle  in  its  normal 
position,  to  adopt  the  extended  posture  for  the  limb.  At  the  end  of 
seven  or  eight  days  remove  the  splint,  and  exercise  the  joint  gently 
every  two  or  three  days. 

Whatever  treatment  is  pursued,  anchylosis  will  be  often  found  fol- 
lowing the  injury. 

10.  Fracture  through  the  Internal  Condyle. — This  variety  of  fracture  is 
met  with  almost  exclusively  in  childhood.  It  is 
caused  by  falls  upon  the  point  of  the  elbow.  The 
line  of  fracture  passes  usually  from  a point  about 
half  an  inch  above  the  epicondyle  outwards  into 
the  joint,  as  seen  in  Fig.  845.  The  fragment  is 
generally  displaced  upwards,  backwards,  and  a : 
little  inwards,  though  it  may  occur  forwards  and 
inwards.  I have  a specimen  in  which  the  dis- 
placement has  taken  place  directly  upwards. 

Symptoms. — The  ulna  being  carried  backwards 
with  the  condyle  it  will  cause  a projection  of  the 
olecranon  when  the  forearm  is  extended;  the 
prominence  disappearing  again  in  flexing  the 
limb.  In  extension  also  the  end  of  the  humerus 
will  form  a tumor  in  the  bend  of  the  elbow.  If 
the  finger  be  put  on  the  condyle,  by  flexing  and 
extending  the  forearm,  crepitus  will  be  perceived. 
Treatment. — This  fracture  should  be  treated  in 
the  same  manner  as  that  of  the  outer  condyle.  The  elbow  should  be 
inspected  every  day  so  as  to  watch  the  progress  of  the  case,  and  to 
correct  any  undue  or  hurtful  pressure  upon  the  part. 

At  the  end  of  a week  remove  the  splint,  and  begin  to  impose  passive 
motion  upon  the  joint,  and  repeat  it  every  two  or  three  days. 

As  in  the  previous  variety  of  fracture,  anchylosis  will  often  attend 
the  best  conducted  treatment. 


Fracture  of  the  internal 
condyle. 


11.  Fracture  through  the  Internal  Epicondyle. — The  little  projection 
upon  the  inner  condyle,  called  the  epicondyle,  may  be  broken  by  falls 
upon  the  inner  side  of  the  elbow. 

I saw  a case  with  Dr.  Stone,  of  Washington,  in  a bov  fourteen 
years  of  age,  who  fell  from  a cart  to  the  ground,  striking  upon  the 
inner  side  of  the  elbow,  where  the  skin  was  a little  bruised  ; the  epi- 
condyle was  displaced  somewhat  upward.  The  compress  was  placed 
above  the  displaced  fragment,  which  could  easily  be  brought  down, 


FRACTURE  OF  THE  RADIUS  AND  ULNA, 


423 


and  confined  by  a figure  of  8 bandage ; tbe  arm  was  then  placed  in  a 
rectangular  splint  of  pasteboard. 

In  seven  days  the  splint  was  removed,  and  the  joint  exercised ; the 
treatment  was  continued  for  a few  days  longer,  when  the  apparatus 
was  entirely  abandoned ; the  boy  recovered  with  all  the  functions  of 
the  limb  intact. 

In  most  of  the  recorded  cases  of  this  injury  the  displacement  of  the 
fragment  has  been  downwards. 

It  will  be  proper  to  add  here,  that  the  treatment  recommended  in 
the  above  sections  for  fracture  of  the  condyles  is  different  from  that 
pursued  and  recommended  by  Dr.  Warren,  of  Boston,  who  says  that 
“ in  the  treatment  of  fractures  of  the  condyles  of  the  os  humeri,  a 
course  is  usually  recommended  which  he  believes  to  be  hurtful,  inas- 
much as  it  favors  tbe  worst  consequences  of  the  injury,  namely,  loss 
of  motion  in  the  joint.  By  this  mode  of  treatment,  the  fractured  piece 
becomes  sufficiently  fixed  to  create  partial  anchylosis ; and  there  is  so 
much  pain  afterwards  in  the  proposed  passive  movements  as  to  cause 
the  omission  of  these  measures  until  permanent  stiffness  takes  place. 
The  proper  course  in  the  management  of  these  accidents,  he  conceives 
to  be:  1st.  To  apply  no  splints,  but  in  the  earlier  days  to  make  use 
of  the  proper  means  to  prevent  inflammation.  2d.  To  accustom  the 
patient  to  early  and  daily  movements  of  flexion  and  extension. 
3d.  When  the  action  of  the  joint  becomes  limited,  to  overcome  the 
resistance  by  force,  and  repeat  it  daily  until  the  tendency  of  the  joint 
to  stiffen  ceases.” 

Fracture  of  the  Radius  and  Ulna  (Fig.  346).  Causes. — Fracture 
of  both  the  radius  and  ulna  results  from  direct  blows  upon  the  forearm, 
and  from  indirect  force,  the  patient  falling  upon  the  palms 
of  the  hands,  with  the  arms  thrown  forward. 

The  fracture  may  be  simple  or  comminuted,  or  com- 
pound, and  is  usually  seated  in  the  middle  and  lower 
thirds  of  the  bones.  The  upper  part  of  the  ulna  is 
stouter  than  it  is  elsewhere,  and  is  covered  with  a thick 
layer  of  muscles,  which  amply  protects  it.  These  cir- 
cumstances explain  the  rarity  of  fracture  in  the  upper 
third  of  the  bone. 

Both  bones  are  commonly  broken  at  or  near  the 
same  level,  though  the  reverse  may  occur.  The  frag- 
ments may  be  displaced  in  any  direction;  that  most 
often  observed  is  where  they  are  pushed  either  to  the 
radial  or  ulnar  side  of  the  forearm ; they  also  may  some- 
times approximate  each  other.  There  can  occur  but 
little  displacement  in  the  direction  of  the  length  of  the 
bones  in  consequence  of  the  connection  of  the  inter- 
osseous ligament  to  their  inner  borders. 

Symptoms. — The  symptoms  are  inability  to  pronate 
and  supinate  the  forearm;  preternatural  mobility;  de- 
formity at  the  seat  of  fracture;  and  crepitus  by  press- 
ing the  fragments  in  opposite  directions.  F . 

Prognosis* — In  simple  fracture  of  both  bones,  and  iower  third.  6 


Fig.  346. 


424 


SPECIAL  FRACTURES. 


under  proper  treatment,  union  will  take  place  between  three  and  five 
weeks,  without  apparent  deformity. 

It  may,  however,  be  delayed  in  rare  cases  for  months,  or  even  may 
not  take  place  at  all.  Sometimes  it  happens  that  one  or  the  other 
bone  unites  promptly  in  the  usual  time,  while  union  in  the  other  is 
delayed. 

Improper  dressings  can  destroy  the  functions  of  pronation  and  supi- 
nation by  pressing  the  radius  and  ulna  together  while  the  consolida- 
tion is  being  effected. 

Treatment.- — The  reduction  is  accomplished  by  making  extension 
and  counter-extension  from  the  wrist  and  elbow,  while  the  surgeon 
presses  with  his  fingers  upon  the  front  and  back  of  the  forearm,  over 
the  interosseous  space,  so  as  to  force  the  bones  asunder. 

In  applying  the  retentive  apparatus  it  was  formerly  the  custom  to 
put  a bandage  upon  the  limb  from  the  hand  to  the  shoulder  before 
the  splints  were  laid  on.  It  is  now  very  properly  discarded,  inasmuch 
as  the  practice  effected  exactly  what  the  surgeon  endeavors  to  pre- 
vent— a drawing  together  of  the  radius  and  ulna. 

The  ordinary  apparatus  consists  of  two  flat  splints  of  greater  width 
than  the  forearm,  and  padded  in  such  a manner  that  they  may  be  a 
little  thicker  along  the  centre  than  at  the  margins;  they  should  be  of 
unequal  length,  the  anterior  reaching  from  the  bend  of  the  elbow  to 
the  tips  of  the  fingers ; and  the  posterior,  from  the  elbow  to  the  roots 
of  the  fingers.  These  splints  are  laid  upon  the  forearm,  and  confined 
by  a roller  bandage.  The  arm  ought  to  be  examined  every  day,  to 
be  sure  that  no  injurious  pressure  is  exercised  at  any  point. 

Some  surgeons,  instead  of  padding  the  splint,  employ  graduated 
compresses  beneath  them  in  order  to  force  the  muscles  towards  the 
interval  separating  the  bones.  In  this  case,  as  suggested  by  Ndlaton, 
the  compresses  ought  to  be  short,  so  as  not  to  press  upon  the  ulna 
and  radial  arteries. 

When  the  splints  have  been  properly  secured  to  the  forearm  it  will 
be  advisable,  if  it  is  possible,  to  put  the  forearm  in  a posture  of  supi- 
nation, and  projecting  in  front  of  the  body,  while  the  elbow  rests 
against  the  side.  In  this  position  the  fragments  will  be  more  easily 
brought  together,  and  the  bones  will  encroach  less  upon  the  interos- 
seous space,  thus  rendering  any  impairment  of  the  function  of  supi- 
nation, when  consolidation  occurs,  much  less  likely  to  follow ; there 
will  also  be  less  tendency  to  lateral  distortion. 

Although  these  advantages  are  manifest,  yet  there  are  some  sur- 
geons who  have  overlooked  them,  and  directed  the  forearm  to  be 
placed  midway  between  supination  and  pronation,  with  the  plane  of 
the  hand  vertical. 

In  compound  fractures  it  may  be  necessary  to  put  the  forearm  in  a 
posture  of  pronation;  in  such  cases  the  limb  may  be  laid  upon  a sim- 
ple flat  board,  and  loosely  connected  to  it,  above  and  below,  by  a few 
turns  of  a roller. 

If  the  person  is  able  to  walk  about,  the  apparatus  of  Mayor  may  be 
employed,  which  consists  of  a board  a little  longer  than  the  forearm 


FRACTURE  OF  THE  RADIUS. 


425 


and  hand,  a cushion,  a cord  for  suspension, 
and  three  cravats.  “The  fracture  being 
reduced,  the  forearm  is  placed  upon  the 
cushioned  boards  a,  b (Fig.  347),  which  is 
immediately  suspended  from  the  patient’s 
neck  by  means  of  the  arcdoops  e,  e,  the 
ring  /,  and  the  cervical  cravat  g.  The 
second  cravat,  c,  is  now  placed  under  the 
wrist,  and  crossed  upon  the  back  of  the 
hand,  the  tails  being  then  made  to  embrace 
the  cushioned  board,  and  knotted  at  the 
anterior  border,  as  represented  at  h.  The 
third  cravat  is  made  to  pass  around  the 
apparatus  at  its  upper  part,  so  as  to  con-  Mayor’s  appara“  fracture  of  the 
fine  the  corresponding  portion  of  the  fore- 
arm, and  is  then  knotted  as  the  other.  If  it  be  necessary  to  counteract 
any  lateral  displacement,  a fourth  cravat  may  be  made  use  of,  to  serve 
as  a traction  ligature ; which  will  of  course  be  knotted  at  the  inner 
margin  of  the  suspension-board.” 

If  the  patient  be  confined  to  bed,  the  apparatus  may  be  supported 
by  a cord  hanging  from  the  ceiling,  or  from  an  upright  fastened  to 
the  bedstead. 

Fracture  of  the  Radius. — Fracture  of  the  radius  is  more  frequent 
than  that  of  both  bones  of  the  forearm,  or  of  the  ulna  alone,  and  the 
right  is  more  often  broken  than  the  left. 

There  are  three  varieties  of  this  fracture  which  we  shall  consider 
separately.  1st.  Fracture  of  the  upper  extremity.  2d.  Fracture  of 
the  shaft.  3d.  Fracture  of  the  lower  extremity. 

1.  Fracture  of  the  Upper  Extremity  of  the  Radius.  Causes. — Frac- 
ture of  the  upper  extremity  of  the  radius  is  the  least  frequent  of  the 
three  varieties,  and  is  produced  by  direct  blows  upon  the  part,  and  by 
counter-stroke. 

The  line  of  fracture  may  be  above  or  below  the  insertion  of  the 
biceps  muscle. 

Symptoms. — In  fracture  through  the  neck  of  the  radius,  which  is 
exceedingly  rare,  the  biceps  will  draw  the  superior  end  of  the  lower 
fragment  upwards,  forwards,  and  inwards,  while  the  supinator  radii 
brevis  will  displace  the  head  slightly  outwards,  perhaps,  forming  a 
prominence  in  front  of  the  elbow ; there  will  be  loss  of  voluntary 
supination  and  pronation ; if  the  surgeon  grasps  the  elbow  in  his  left 
hand  pressing  with  the  thumb  upon  the  head  of  the  radius,  the  latter  will 
not  be  found  to  move  when  he  supinates  and  pronates  the  forearm 
with  his  right;  the  hand  will  be  found  in  a prone  position,  and  crepitus 
will  be  perceived  during  the  movements  executed  in  the  examination. 

If  there  is  much  tumefaction,  the  diagnosis  will  be  exceedingly  dif- 
ficult, if  not  impracticable. 

Treatment. — Bend  the  forearm  at  right  angles  to  relax  the  biceps, 
place  a rectangular  splint  upon  the  posterior  surface  of  the  limb,  and 
a compress  in  the  bend  of  the  elbow,  and  then  confine  the  whole  with 
a roller  bandage ; support  the  arm  in  a sling. 


Fig.  347. 


426 


SPECIAL  FRACTURES. 


2.  Fracture  of  the  Shaft  of  the  Radius. — Fracture  of  the  shaft  of  the 
radius  occurs  most  frequently  in  its  lower  third. 

Causes. — Direct  injury  to  the  bone,  and  by  falls  upon  the  palms  or 
backs  of  the  hand  when  the  arm  is  stretched  forward. 

The  displacement  of  the  fragments  that  occur  will  depend  in  a great 
measure  upon  the  nature  and  direction  of  the  force.  They  may  both 

be  depressed  towards  the 
ulna,  or  be  thrown  forwards, 
backwards,  or  outwards. 

The  Fig.  348  shows  the 
upper  fragment  displaced 
forwards  by  the  action  of  the 
biceps  and  pronator  radii 
teres,  while  the  lower  one  is 
drawn  towards  the  ulna  by 
the  pronator  quadratus,  and 
supinator  longus. 

Treatment.  — The  splints 
required  in  the  treatment  of  this  fracture  are  the  same  as  those  de- 
scribed for  fracture  of  both  bones. 

3.  Fracture  of  the  Lower  Extremity  of  the  Radius. — Fracture  of  the 
lower  extremity  of  the  radius  occurs  most  frequently  within  an  inch 
and  a half  of  the  articulating  surface,  and  constitutes  what  is  known 
as  “Colles’  fracture.” 

The  line  of  separation  is  generally  horizontal,  though  it  may  be 
oblique  from  above  downwards  and  from  behind  forwards,  or  the 
reverse. 

In  the  injury  known  under  the  name  of  “Barton’s  fracture”  this  line 
runs  upwards  and  backwards  from  the  joint,  separating  a greater  or 
less  extent  of  the  articulating  surface  of  the  radius  from  the  shaft. 

Cause.- — This  fracture  always  results  from  falls  upon  the  palm  or 
back  of  the  hand  while  the  arm  is  outstretched. 

Symptoms. — The  characteristic  appearance  of  this  injury  is  seen  in 
Fig.  349.  The  lower  fragment  of  the  radius  is  carried  backwards,  up- 


Fig.  348. 


Fig.  349. 


Fracture  of  tlie  radius  near  its  lower  end. 


wards,  and  outwards  by  the  extensors  of  the  thumb  and  the  supinator 
longus  displacing  the  carpus  and  metacarpus  in  that  direction,  and 
forms  a tumor  upon  the  back  of  the  wrist ; above  this  there  is  a well- 
marked  depression.  In  front  another  prominence  is  observed  extend- 
ing about  one-third  up  the  forearm;  the  hand  falls  towards  its  radial 
margin,  while  the  styloid  process  of  the  ulna  projects  prominently  in 


FRACTURE  OF  THE  RADIUS. 


427 


the  direction  of  the  palm ; by  grasping  the  hand  and  moving  it, 
crepitus  may  be  made  manifest. 

Treatment. — The  reduction  of  the  fracture  is  accomplished  by  making 
extension  from  the  hand,  and  at  the  same  time  exercising  pressure 
upon  the  tumor  at  the  back  of  the  wrist  from  behind  forwards. 

The  indication  to  fulfil  in  the  use  of  apparatus  is  manifest,  namely, 
to  incline  the  hand  to  the  ulnar  border  of  the  forearm  and  retain  it  in 
that  position. 

For  this  purpose  Dupuytren  recommended  a splint  made  of  a bar 
of  iron  (Fig.  350),  about  an  inch  wide  and  of  the  length  of  the  forearm, 
and  which,  at  its  lower  extremity, 
opposite  the  part  corresponding 
with  the  wrist,  curves  downwards 
in  a semi-circle,  to  the  concavity 
of  which  some  buttons  are  placed 
at  equal  distances. 

To  apply  the  splint,  place  be- 
neath it  upon  the  ulnar  border 
of  the  forearm  a narrow  pad,  ex- 
tending from  the  styloid  process 
of  the  ulna  to  the  elbow,  and  about  one  inch  thick  below,  gradually 
' tapering  upwards ; then  with  a roller  secure  it  to  the  limb  ; arriving  at 
the  wrist  make  turns  around  the  radial  border  of  the  hand  and  curved 
extremity  of  the  splint,  so  as  to  maintain  the  hand  in  a position  of 
forced  adduction. 

Sir  A.  Cooper,  in  treating  this  fracture,  applied  a roller  from  the 
wrist  to  the  elbow,  and  then  two  padded  splints  upon  the  anterior  and 
posterior  surfaces  of  the  forearm,  reaching  from  the  elbow  to  the  roots 
of  the  fingers ; the  splints  were  secured  to  the  limb  by  a second  roller, 
beginning  at  the  wrist.  The  forearm  is  now  placed  in  a sling  in  a 
position  midway  between  pronation  and  supination,  so  that  the  weight 
of  the  hand,  moving  freely  between  the  splints,  may  adduct  it. 

The  method  pursued  by  Nelaton  was  to  apply  a pistol-shaped  splint 
(Fig.  351),  well  padded,  to  the  dorsal  surface  of  the  forearm,  reaching 


Fig.  351. 


from  the  tips  of  the  fingers  to  the  elbow,  and  a straight  one  upon  its 


Fig.  350. 


Dupuytreir  s apparatus  for  fracture  of  the  radius 
near  the  wrist. 


428 


SPECIAL  FRACTURES. 


palmar  surface  extending  from  the  wrist  to  the  elbow;  a compress  is 
to  be  placed  beneath  the  curved  splint  and  over  the  lower  fragment, 
while  the  straight  splint  must  be  placed  opposite  the  upper  fragment, 
and  also  along  its  radial  margin,  to  prevent  the  tendency  which  this 
part  of  the  radius  has  to  pronation.  The  splints  are  secured  to  the 
arm  with  a roller  bandage. 

Another  plan,  recommended  by  this  distinguished  surgeon,  is  the 
following : Place  a square  compress  over  the  lower  fragment  at  the 
back  of  the  forearm,  and  a long  compress  upon  its  palmar  surface 
reaching  from  the  elbow  to  a point  just  above  the  lower  margin  of  the 
prominence  upon  that  side.  Upon  these  compresses  lay  two  straight 
splints  extending  from  the  wrist  to  the  elbow,  and  confine  them  by  a 
roller  bandage  or  three  broad  strips  of  adhesive  plaster;  the  hand  is 
thus  left  free  to  take  a position  of  adduction  by  its  own  weight,  while 
the  compresses  force  the  fragments  in  directions  opposite  those  of  their 
displacement. 

The  splint  devised  by  Dr.  Bond,  of  Philadelphia,  is  also  an  efficient 
one  in  the  treatment  of  this  injury;  it  is  prepared  in  the  following 
manner : Cut  from  any  sort  of  light  wood  a splint  having  the  shape 
of  that  seen  in  Fig.  852,  and  long  enough  to  extend  from  the  elbow 


Fig.  352. 


to  the  second  joints  of  the  fingers.  To  its  lower  extremity  fasten  with 
screws  or  nails  a cylindrical  piece  of  wood  B , which  is  intended  to  sup- 
port the  palm  when  the  forearm  reposes  on  the  splint. 

To  make  it  more  comfortable  narrow  strips  ( D ) of  binders’  board  or 
leather  may  be  nailed  to  the  lateral  edges  of  the  splint,  Fig.  853. 


Fig.  353. 


Bond’s  splint  with  strips  attached. 


The  apparatus  is  applied  by  padding  the  splint  with  cotton-batting 
or  flannel,  and  laying  the  forearm  with  the  fracture  reduced  upon  it; 
above  and  below  the  point  of  injury,  a compress  of  suitable  thickness 
is  to  be  placed,  and  then  the  whole  dressing  inclosed  with  a roller 
bandage. 


FRACTURE  OF  THE  RADIUS. 


429 


Should  the  elegant  splint  of  Dr.  Bond  not  be  attainable,  one  some 
what  similar  in  form  may  be  prepared  as  directed  by  Dr.  Hays,  from 
any  sort  of  wood  that  may  be  at  hand ; it  is  cut  into  the  shape  seen 
in  Fig.  354.  As  a substitute  for  the  cylindrical  piece  of  wood,  a 


Fig.  354. 


common  roller  can  be  used,  secured  to  the  end  of  the  splint  bjr  a 
bandage,  as  shown  in  the  cut. 

Dr.  E.  P.  Smith  has  modified  Bond’s  splint  in  such  a manner  that 
one  splint  may  be  employed  upon  either  arm.  This  object  is  attained 
by  articulating  the  palm-block  D (Fig.  355)  with  the  guttered  arm- 

Fig.  355. 


C 


Smith’s  modification  of  Bond’s  splint.  Back  view. 


splint  A,  by  means  of  a circular  joint  which  may  be  fixed  at  any 
angle  by  a thumb-screw  placed  upon  its  posterior  surface. 

The  range  of  motion  of  the  palm-block  is  indicated  in  Fig.  356  by 
the  dotted  arc  C C. 


Fig.  356. 


Same  splint.  Front  view. 

The  apparatus  employed  by  Dr.  Hamilton  is  directed  to  be  pre= 
pared  extemporaneously  from  a wooden  shingle,  cut  into  the  requisite 


430 


SPECIAL  FRACTURES. 


shape  and  length  (Fig.  357),  the  length  being  obtained  by  measuring 
from  the  front  of  the  elbow-joint,  when  the  arm  is  flexed  to  a right 

angle,  to  the  metacarpo-phalangeal  ar- 
Fig.  357.  ticulations.  It  ought,  indeed,  to  fall 

half  an  inch  short  of  the  bend  of  the 
elbow,  to  render  it  certain  that  it 
shall  make  no  uncomfortable  pressure 
at  this  point;  and  the  direction  to 
measure  with  the  arm  flexed  is  of 

Hamilton’s  splint  for  fracture  of  tire  radius.  Sufficient  lmpOltaUCe  tO  Warrant  a 

repetition.  The  breadth  of  the  splint 
should  be,  in  all  its  extent,  just  equal  to  the  breadth  of  the  forearm  in 
its  widest  part,  so  that  there  shall  be  no  lateral  pressure  upon  the 
bones.  If  the  splint  is  of  unequal  breadth,  the  roller  cannot  be  so 
neatly  applied,  and  is  more  likely  to  become  disarranged.  Thus  con- 
structed, it  is  to  be  covered  with  a sack  of  cotton  cloth,  made  to  fit 
lightly,  with  the  seam  along  its  back,  and  afterwards  stuffed  with 
cotton-batting  or  with  curled  hair.  These  materials  may  be  passed 
in  and  easily  adjusted,  whenever  they  are  most  needed,  from  the  open 
extremities  of  the  sack.  While  preparing,  the  splint  must  be  occa- 
sionally applied  to  the  arm  until  it  fits  accurately  every  part  of  the 
forearm  and  hand,  only  that  the  stuffing  must  be  rather  more  firm  a 
little  above  the  lower  end  of  the  upper  fragment.  The  open  ends  of 
the  sac  are  then  to  be  neatly  stitched  over  the  ends  of  the  splint. 
This  splint  is  now  to  be  laid  directly  upon  the  skin  without  any  inter- 
mediate compresses  or  rollers.  In  all  cases  it  is  better  to  employ, 

also,  at  least  during  the  first  fort- 
Fig.  358.  night,  a straight  dorsal  splint,  of 

the  same  breadth  as  the  palmar 
splint,  and  of  sufficient  length  to 
extend  from  the  elbow  to  the 
middle  of  the  metacarpus  (Fig. 
358).  This  should  be  covered 
and  stuffed  in  the  same  manner 
as  the  palmar  splint,  except  that 
here  the  thickest  and  firmest  part 
of  the  splint  must  be  opposite  the 
carpus,  and  the  lower  end  of  the 
lower  fragment.  It  will  answer 
the  indications  also  a little  more 
completely  if,  at  this  point,  the 
padding  is  thicker  on  the  radial 
than  on  the  ulnar  side.  The  ap- 
plication of  the  apparatus  is  effect- 
ed by  restoring  the  fragments  to 
place,  in  case  of  Codes’  fracture, 
by  pressing  forcibly  upon  the  back 
of  the  lower  fragment,  the  force 
being  applied  near  the  styloid 
apophysis  of  the  radius,  the  arm 


Apparatus  applied. 


FRACTURE  OF  THE  ULNA. 


431 


is  to  be  flexed  upon  the  body,  and  placed  in  a position  of  semi-prona- 
tion, when  ihe  splints  are  to  be  applied  and  secured  with  a sufficient 
number  of  turns  of  the  roller,  taking  especial  care  not  to  include  the 
thumb,  the  forcible  confinement  of  which  is  always  painful  and  never 
useful. 

Dr.  J.  Rhea  Barton  recommended  the  application  of  two  broad, 
straight,  and  padded  splints  to  the  dorsal  and  palmar  aspects  of  the 
forearm,  extending  from  the  elbow  to  the  tips  of  the  fingers ; beneath 
the  splints  two  compresses  are  placed,  one  over  the  posterior  surface 
of  the  lower  fragment,  the  other  over  the  anterior  surface  of  the  upper 
one ; a roller  bandage  is  used  to  secure  the  splint  to  the  forearm. 

Colies  also  used  straight  splints. 

Prof.  Fauger,  of  Copenhagen,  discarding  all  sorts  of  splints  in  the 
treatment  of  this  injury,  advises  the  forearm  to  be  laid  upon  a wedge- 
shaped  support,  inclining  towards  the  patient,  with  the  hand  hanging 
over  the  perpendicular  end  or  base  of  the  support. 

Fracture  of  the  Ulna. — The  varieties  of  fracture  of  the  ulna 
may  be  described  under  the  following  heads : 1st.  Fracture  of  the 
olecranon  process.  2d.  Fracture  of  the  coronoid  process.  3d.  Frac- 
ture of  the  body  and  lower  extremity. 

1.  Fracture  of  the  Olecranon  Process.  Causes. — Fracture  of  the  olecra- 
non process  is  generally  caused  by  falls  upon  the  point  of  the  elbow, 
or  by  direct  blows ; it  is  also  occasionally  seen  to  result  from  violent 
contraction  of  the  triceps. 

The  line  of  fracture  may  pass  through  any  point  of  the  process  from 
the  base  to  the  apex,  but  it  generally  occurs  midway  between  these  points. 
Its  direction  is  commonly  trans- 
verse, occasionally  oblique,  either 
from  before  downwards  and  back- 
wards, or  from  above  downwards, 
and  from  behind  forwards. 

The  olecranon  is  displaced  up- 
wards, or  in  the  direction  of  the 
line  of  action  of  the  triceps,  pro- 
ducing an  interval  between  it  and 
the  ulna  from  a few  lines  to  two 
inches  according  to  the  extent  of 
the  laceration  of  the  tendinous  in- 
sertion of  that  muscle. 

Symptoms. — The  limb  will  be  in  a posture  of  semi-flexion,  and  the 
patient  will  be  unable  either  to  flex  or  to  extend  it.  A depression  will 
he  observed  above  the  point  of  the  elbow  caused  by  the  absence  of  the 
olecranon  and  the  tendon  inserted  into  it;  that  process  can  be  felt  drawn 
up  into  its  new  position.  If  the  arm  is  extended,  the  olecranon  may  be 
easily  brought  down,  and,  by  rubbing  it  laterally  against  the  ulna, 
crepitus  will  be  perceived.  To  these  symptoms  are  to  be  added  pain 
and  swelling  at  the  seat  of  injury. 

Prognosis. — If  the  fragment  is  kept  in  contact  with  the  ulna,  bony 
union  may  occur,  but  in  the  majority  of  cases  the  cure  is  brought 
about  by  ligamentous  union. 


Fig.  359. 


432 


SPECIAL  FRACTURES. 


Treatment. — Extend  the  forearm  to  relax  the  triceps,  bring  down 
the  olecranon,  and  secure  it  in  apposition  with  the  ulna  by  an  appro- 
priate apparatus. 

The  method  pursued  by  Sir  A.  Cooper  was  “to  place  a piece  of 
linen  longitudinally  on  each  side  of  the  joint ; a wetted  roller  is  applied 


Fig.  360. 


Sir  A Cooper’s  apparatus  for  fracture  of  the  olecranon. 


above  the  elbow,  and  another  below  it ; the  extremities  of  the  linen 
are  then  to  be  doubled  down  over  the  rollers  and  tightly  tied,  so  as  to 
cause  an  approximation  of  the  fragment;  thus  the  portions  of  bone 
are  brought  and  held  together;  a splint  well  padded  is  to  be  applied 
upon  the  forepart  of  the  arm  to  preserve  it  in  a straight  position,  and 
confined  to  it  by  a circular  bandage.” 

If  there  is  much  inflammation  before  applying  this  apparatus,  it 
will  be  necessary  to  have  recourse  to  leeches  and  cold  water- dressings 
for  two  or  three  days. 

The  apparatus  of  Mr.  Amesbury  consists  of  two  belts,  one  fastened 
above  the  olecranon,  and  the  other  upon  the  forearm,  which  he  con- 
nected together  by  lateral  straps  and  buckles  to  draw  the  upper  frag- 
ment down ; upon  the  anterior  surface  of  the  arm  a guttered  splint  is 
to  be  applied  to  keep  the  limb  fully  extended. 

In  an  emergency,  the  plan  recommended  by  M.  Mayor  may  be  pur- 
sued : The  arm  is  placed  in  an  extended  position ; to  its  anterior  sur- 
face a pasteboard  splint  is  moulded  (or  a splint  of  any  other  sort  may 
be  used  if  the  pasteboard  is  not  at  hand),  extending  from  about  three 
inches  above  the  elbow  to  the  tips  of  the  fingers  ; the  olecranon  is  now 
brought  in  contact  with  the  ulna,  and  above  it  is  placed  a compress, 

Fig.  361. 


Mayor's  apparatus  for  fractured  olecranon. 

secured  in  position  by  a cravat  tied  around  it  and  under  the  arm,  the 
tails  of  the  cravat  being  permitted  to  hang  towards  the  hand  upon  the 
back  of  the  forearm ; another  cravat  is  tied  around  the  lower  part  of 
the  splint  and  the  metacarpus,  when  the  tails  of  the  two  cravats  are 
knotted  together  posteriorly  at  the  middle  of  the  forearm. 

Desault  objects  to  placing  the  arm  in  an  extended  position  (an  ob- 
jection concurred  in  by  both  Velpeau  and  Ndlatou),  and  recommends 


FRACTURE  OF  THE  ULISTA. 


483 


that  the  forearm  be  kept  midway  between  semiflexion  and  complete 
extension  by  an  angular  splint.  The  reason  assigned  is,  that  in  frac- 
ture of  the  olecranon  at  its  base  the  extended  position  causes  the  bra- 
chialis  anticus  to  draw  the  upper  end  of  the  ulna  somewhat  forwards, 
so  that  the  fragments  cannot  be  kept  in  a straight  line ; and  if  union 
should  occur  under  these  circumstances,  it  will  be  at  their  posterior 
edges  only,  thus  forming  an  open  angle  opposite  the  joint  into  which 
the  substance  effused  for  uniting  the  fracture  will  be  thrown,  and  by 
its  subsequent  organization  impede  the  motions  of  the  elbow. 

After  the  splints  have  remained  on  the  limb  for  three  weeks  they 
must  be  removed,  and  passive  motion  impressed  upon  the  joint  to 
prevent  anchylosis. 

2.  Fracture  of  the  Coronoid  Process.- — Fracture  of  the  coronoid  process 
of  the  ulna  is  seen  in  Fig.  362.  It  is  of  extremely  rare  occurrence ; 
so  much  so,  indeed,  that  there  are  but  few  unquestionable  instances  of 
the  kind  upon  record. 


Fracture 

M.  Kiihnholtz,  of  Montpellier,  describes  two  varieties  of  the  injury, 
the  first  consists  in  the  simple  knocking  off  of  the  top  of  the  process 
either  by  direct  force,  or  what  is  more  frequent,  by  falls  upon  the 
palms  with  the  arms  thrown  forward,  the  weight  of  the  body  being 
chiefly  sustained  upon  the  hypothenar  margin  of  the  hand.  The  in- 
jury is  recognized  by  the  inability  of  the  patient  to  flex  the  arm 
until  the  reduction  is  effected,  which  is  very  difficult ; by  the  presence 
of  a small,  hard,  and  freely  movable  body  in  front  of  the  joint;  and 
lastly,  by  a sudden  cracking  felt  by  the  person  in  the  bend  of  the 
elbow  at  the  moment  of  the  fall. 

The  second  variety  involves  the  base  of  the  process,  and  is  always 
produced  by  direct  violence,  and  is  generally  accompanied  by  a dislo- 
cation backwards  of  the  ulna,  or  a fracture  of  one  or  both  of  the  bones 
of  the  forearm,  and  so  much  laceration  of  the  soft  parts  that  amputa- 
tion is  often  required. 

Fracture  of  this  process  cannot  result  from  muscular  action,  inas- 
much as  there  are  no  fibres  inserted  into  it  that  could  exercise  the 
required  amount  of  force  to  effect  it.  The  brachialis  anticus  is  inserted 
at  its  base. 

Treatment. — Flex  the  forearm  at  right  angles,  and  mould  to  the  pos- 
terior surface  of  the  limb  a splint  of  gutta-percha,  pasteboard,  or  plas- 
I ter  of  Paris ; place  a compress  upon  the  fold  of  the  arm,  and  then 
inclose  the  apparatus  in  a roller  bandage  from  the  hand  upwards. 

At  the  expiration  of  the  third  week  the  splint  should  be  removed 
and  the  elbow  gently  exercised  daily  to  prevent  the  occurrence  of  an- 
chylosis. 

3.  Fracture  of  the  Shaft  and  Lower  Extremity  of  the  Ulna. — The 
body  of  the  ulna  is  most  frequently  broken  at  its  lower  third  in  an 
28 


of  the  coronoid  process. 


434 


SPECIAL  FRACTURES. 


Fig.  363. 


Fig.  364. 


Apparatus  for  fracture  of  the  coronoid  process. 


oblique  direction,  as  seen  in  Fig.  364.  It  is  commonly 
caused  by  a blow  or  fall  upon  the  ulnar  border  of  the 
forearm ; a fall  upon  the  palm  of  the  hand  may  also 
produce  it. 

Symptoms. — The  upper  extremity  of  the  bone  will  be 
held  in  position  by  its  connections  at  the  elbow,  while 
the  lower  one  will  be  drawn  by  the  pronator  quadratus 
outwards,  or  towards  the  radius,  causing  a depression 
upon  the  ulnar  border  of  the  forearm  that  may  be  easily 
seen  and  felt ; crepitus  may  be  elicited  by  rubbing  the  ends  of  the 
bones  together  in  opposite  directions.  In  some  cases  the  displacement 
of  the  lower  fragment  deflects  the  hand  to  the  ulnar  side  of  the  axis 


Fracture  of  the 
shaft  of  the  ulna. 


of  the  forearm. 

Treatment. — If  there  exist  displacement  of  the  fragments,  it  must 
be  corrected  by  making  moderate  extension  upon  the  hand,  while  the 
bones  of  the  forearm  are  forced  asunder  by  pressure  exercised  with 
the  fingers,  otherwise  they  will  become  joined  together  by  osseous 
union  and  the  functions  of  pronation  and  supination  will  be  destroyed. 

After  the  bones  have  been  restored  to  their  proper  position  the  limb 
may  be  put  upon  a splint,  similar  in  construction  to  that  of  Bond, 
with  the  difference  that  its  lower  end  must  curve  in  the  opposite  direc- 
tion, so  that  the  hand  may  be  held  in  a position  of  abduction,  to  throw 
the  upper  end  of  the  lower  fragment  away  from  the  radius. 

Fracture  of  the  Carpus. — Fracture  of  the  bones  of  the  wrist  is 
always  the  result  of  direct  and  great  violence,  which  commonly  lace- 
rates the  soft  tissues  to  such  a degree  as  to  frequently  necessitate 
amputation. 

Treatment. — As  there  will  be  much  inflammation  in  these  cases,  it  is 
advisable  to  simply  put  the  hand  upon  a broad  board  in  the  most  con- 
venient posture  for  the  application  of  the  needed  dressings,  and  to 
facilitate  the  escape  of  any  pus  that  may  happen  to  accumulate. 

When  the  inflammatory  action  has  been  quelled  by  appropriate 
remedies,  and  the  soft  tissues  healed,  the  wrist  should  be  perseveringly 
exercised  to  prevent  any  loss  of  motion  of  the  joint. 

Fracture  of  the  Metacarpus. — The  metacarpal  bones  suffer  most 


FRACTURE  OF  BONES  OF  THE  LOWER  EXTREMITIES.  435 

frequently  from  fracture  caused  by  direct  violence ; indirect  force  may 
also  cause  it,  as  when  a heavy  blow  is  struck  with  the  clenched  fist. 

The  first  and  fifth  metacarpal  bones  are  more  often  broken  than  the 
others. 

From  the  close  connection  between  these  bones  no  vertical  displace- 
ment can  take  place ; the  ends  of  the  fragments  may  be  pushed  in  any 
other  direction,  though,  perhaps,  it  most  frequently  occurs  backwards. 

Treatment. — The  treatment  is  simple ; consisting  in  the  application 
of  a wooden  or  gutta-percha  splint  to  the  back  of  the  hand  and  fore- 
arm, with  suitable  compresses  to  correct  displacements. 

My  experience  during  the  late  war  in  gunshot  fractures  of  both  the 
carpus  and  metacarpus,  attended  with  profuse  suppuration,  led  me  to 
prefer  an  apparatus  consisting  of  a wire  frame,  applied  to  the  dorsal 
surface  of  the  limb,  reaching  from  a point  just  below  the  shoulder  to 
the  tips  of  the  fingers,  and  secured  to  it  by  broad  strips  of  adhesive 
plaster ; the  limb  was  then  suspended  in  the  frame  by  a cord  hanging 
from  the  ceiling,  or  from  the  top  of  an  upright  lashed  to  the  bedside. 
This  arrangement  permitted  the  easy  application  of  water-dressings, 
or  irrigation,  and  as  it  allowed  the  hand  to  be  placed  in  most  any  pos- 
ture, it  facilitated  the  escape  of  pus.  . 

Fracture  of  the  Phalanges.— Fracture  of  the  phalanges  results 
from  the  same  causes  that  produce  this  injury  in  the  metacarpus. 

The  fragments  may  be  displaced  laterally,  or  be  rotated  upon  their 
axis. 

Treatment. — Eedress  any  displacements  of  the  fragments  that  may 
exist  by  making  extension  and  pressure  upon  the  phalanges,  and  then 
apply  a gutta-percha  or  pasteboard  splint,  which  must  be  secured  with 
a narrow  roller,  or  strips  of  adhesive  plaster.  If  anchylosis  threatens 
to  occur,  the  fingers  should  be  kept  in  a slightly  bent  position. 


Fig.  365. 


A splint  sometimes  used  in  treatment  of  fractured  phalanges  is  seen 
in  Fig.  465. 

SECTION  IY. 

FRACTURE  OF  THE  BONES  OF  THE  LOWER  EXTREMITIES. 

Fracture  of  the  Pelvic  Bones.  1.  Sacrum. — Fracture  of  the 
sacrum  is  caused  by  direct  and  great  violence  applied  to  the  back  of 
the  pelvis.  Its  seat  is  commonly  below  the  sacro-iliac  symphysis,  and 
its  direction  transverse.  The  lower  fragment  is  displaced  forwards 
towards  the  rectum,  and  in  two  of  the  recorded  cases  of  this  injury 
compressed  that  bowel. 


436 


SPECIAL  FBACTUBES. 


Treatment. — An  effort  should  be  made  to  replace  the  lower  frag- 
ment in  its  normal  position  by  exercising  pressure  upon  its  anterior 
surface  with  the  finger  introduced  into  the  rectum.  As  there  is  no 
tendency  of  the  fragments  to  become  displaced  after  the  reduction,  it 
is  only  necessary  to  put  the  patient  into  a recumbent  posture,  and  to 
combat  local  inflammation. 

2.  Coccyx. — Fracture  of  the  coccyx  results  from  falls  upon  the  nates, 
and  from  blows  inflicted  upon  the  lower  extremity  of  the  spine  by 
kicking.  The  bone  is  most  always  displaced  inwards. 

Dr.  Roeser  records  a case  ( Froriep's  Notizen,  1857,  Bd.  II.,  No.  10) 
in  which  the  coccyx  was  displaced  laterally.  It  occurred  in  a large, 
corpulent  woman,  thirty-six  years  of  age,  who  fell  from  a table  upon 
which  she  was  standing  astride  the  back  of  a low  wooden  chair. 
Upon  examination,  a small  swelling  was  felt  on  the  left  side  of  the 
fissure  of  the  buttocks,  which  proved  to  be  the  coccyx  torn  away 
from  the  sacrum,  and  carried  towards  the  descending  ramus  of  the 
left  ischium.  The  reduction  was  accomplished  by  making  firm 
pressure  downwards  and  to  the  right  against  the  displaced  bone. 

Treatment. — The  treatment  of  this  injury  is  the  same  as  in  the 
previous  case.  . 

3.  Ilium. — The  ilium  may  be  fractured  at  any  point — acetabulum, 
ala,  crest,  or  spinous  process. 

The  acetabulum  may  simply  have  its  edge  knocked  off,  or  be  broken 
into  several  pieces,  which  may  become  so  far  separated  as  to  permit 
the  head  of  the  femur  to  be  shoved  into  the  pelvic  cavity. 

This  form  of  injury  proceeds  from  the  same  causes  as  does  fracture 
of  the  neck  of  the  femur,  though  in  general  the  force  inflicted  will  be 
of  greater  intensity. 

The  diagnosis  of  fracture  of  the  acetabulum,  from  a similar  injury 
of  the  neck  of  the  thigh-bone,  and  from  iliac  dislocation,  is  often 
quite  difficult ; though  in  the  event  of  a mistake  in  this  respect,  little 
harm  can  result,  inasmuch  as  the  same  line  of  treatment  is  required 
in  both  varieties  of  fracture. 

If  the  edge  of  the  acetabulum  is  broken  away  and  the  head  of  the 
femur  persistently  ascends  in  spite  of  the  extension  made  upon  the 
limb,  the  retention  of  the  bone  in  the  cotyloid  cavity  may  be  rendered 
more  secure,  by  putting  a broad  belt  around  the  pelvis,  having 
fastened  to  its  under  surface  a padded  metallic  plate  of  a semilunar 
shape  to  press  against  the  trochanter,  and  thus  offer  a solid  resistance 
to  its  ascent. 

Should  the  acetabulum  be  split  in  several  pieces  and  the  head  of 
the  femur  sunk  into  the  pelvic  cavity,  the  pelvic  belt  would  be  useless, 
and  extension  alone  should  be  depended  upon. 

When  the  superior  spinous  process  is  separated  from  the  ala.  the 
patient  should  be  placed  upon  his  back  and  the  lower  extremities 
flexed  and  supported  on  cushions  so  as  to  relax  the  sartorius  muscle. 

4.  Pubis  and  Ischium  (Fig.  366). — Fractures  of  the  pubis  and  ischium 
are  often  associated  together,  and  are  always  caused  by  great  violence 
applied  to  the  pelvis,  as  when  a person  is  crushed  under  a falling 


FRACTURE  OF  THE  FEMUR. 


437 


wall  or  between  two  cars.  Fracture 
of  the  ischium  has  also  resulted  from 
falls,  from  a considerable  height, 
upon  the  nates. 

These  accidents  are  always  dan- 
gerous on  account  of  the  damage 
done  to  the  viscera  of  the  pelvic 
cavity — rupture  of  the  bladder,  ure- 
thra, or  rectum. 

Treatment. — The  treatment  con- 
sists in  rectifying  displacement  of 
the  fragments,  if  any  should  exist, 
by  introducing  the  finger  into  the 
rectum ; or,  in  the  female,  into  the 
I vagina,  and  pressing  them  into  their 
natural  position. 

A catheter  should  be  at  once 
passed  into  the  bladder  and  its 
condition  ascertained. 

The  patient  must  be  put  to  bed  with  his  body  in  that  position  which 
is  most  comfortable  to  him ; no  apparatus  is  required  except,  perhaps, 
when  the  line  of  fracture  has  passed  through  the  symphysis  pubis  and 
accompanied  with  a separation  of  the  pubic  bones,  then,  as  recom- 
mended by  Sir  A.  Cooper,  a pelvic  belt  may  be  applied  to  bring  them 
together. 

Perineal  abscess,  resulting  from  effused  urine,  must  be  promptly 
evacuated  by  deep  incisions. 

Fracture  of  the  Femur. — Fractures  of  the  femur  may  be  divided 
into:  1.  Fractures  of  the  upper  extremity;  2.  Of  the  shaft;  and  3. 
Of  lower  extremity  of  the  femur. 

1.  Fracture  of  the  Upper  Extremity  of  the  Femur. — Under  this  head 
are  placed:  1.  Fracture  of  the  neck  of  the  femur;  and  2.  Fracture 
of  the  trochanter  major. 

a.  Intra- Capsular  Fracture  of  the  Neck  of  the  Femur. — In  intra- 
capsular  fracture  of  the  neck  of  the  femur  the  line  of  fracture,  as  the 
name  implies,  passes  through  the  neck  of  the  bone  inside  of  the  capsu- 
lar ligament. 

Its  position  is  usually  quite  near  the  articulating  head  of  the  bone, 
as  seen  in  Fig.  367,  though  it  may  occur  at  any  point  of  the  neck;  in 
Fig.  368  the  fracture  is  seen  at  its  base. 

The  line  of  fracture  is  commonly  observed  to  be  oblique ; in  some 
cases  it  is  transverse. 

Instances  have  been  recorded  of  incomplete  fracture  occurring  in 
this  portion  of  the  bone;  in  most  cases  the  fragments  are  completely 
separated,  though  rarely  they  have  been  found  impacted  or  interlocked 
by  the  close  contact  of  opposing  surfaces  presenting  corresponding 
indentations  and  projections. 

If  the  fragments  are  free,  the  muscles  will  pull  the  lower  fragment 
upwards  and  backwards,  and,  in  conjunction  with  the  weight  of  the 


Fig.  366. 


Fracture  of  the  pubis  aud  ischium. 


438 


SPECIAL  FRACTURES. 


limb  below,  rotate  it  outwards,  while  the  head  of  the  bone  remains 
immovable  in  the  acetabulum. 

Fig.  367.  Fig.  368. 


Iiitra-capsular  fractures. 


Fig.  369. 


Causes. — Intra-capsular  fracture  is  generally  caused  by  some  moder- 
ate force  acting  upon  the  knee,  or  foot,  forcing  the  femur  toward  the 
acetabulum,  as  sometimes  occurs  in  making  a 
misstep,  or  tripping  and  falling  upon  the  knee. 

It  is  scarcely  ever  met  with  in  persons  under 
fifty  years  of  age ; beyond  this  period  the  bones 
undergo  more  or  less  change  of  structure — the 
cellular  substance  of  the  neck  of  the  femur  be- 
comes more  rarefied  and  its  compact  structure 
thinner.  In  old  women,  too,  the  angle  formed 
by  the  neck  with  the  shaft  diminishes,  and  the 
former  is  thereby  less  able  to  resist  the  influence 
of  external  forces  than  it  would  be  if  nearer  the 
axis  of  the  shaft;  these  circumstances  strongly 
predispose  persons  beyond  the  age  mentioned  to 
the  occurrence  of  this  injury. 

Falls  upon  the  hip  will  also  produce  fracture 
of  the  neck,  and  cases  are  related  where  muscular 
force  alone  caused  it. 

Symptoms. — The  external  characteristics  of 
the  fracture  are  seen  in  Fig.  369.  The  patient 
stands  upon  the  uninjured  extremity  with  the 
body  inclined  forwards;  the  fractured  limb  is 
shortened,  the  knee  and  foot  strongly  everted, 
while  the  heel  is  raised  from  the  ground  and 
rests  in  the  hollow  between  the  tendo-Achillis 
and  the  internal  malleolus  of  the  ankle  of  the 
External  characteristics  of  0pp0Spe  pmp.  The  patient  cannot  walk,  and 

fracture  of  the  neck  of  the  .rr  P c • • j 

femur.  the  slightest  pressure  oi  the  loot  oi  the  injured 


FRACTURE  OF  THE  FEMUR. 


439 


leg  upon  the  ground  causes  pain  in  the  hip-joint ; the  trochanter  major 
will  be  found  nearer  the  crest  of  the  ilium  than  its  fellow,  and  at  the 
same  time  is  less  prominent. 

If  the  patient  be  placed  in  the  recumbent  posture,  the  broken  limb 
will  still  be  everted  by  its  own  weight  and  the  contraction  of  external 
rotation  muscles. 

By  the  application  of  moderate  force  the  broken  limb  may  be  re- 
stored to  its  normal  length,  and  during  rotative  movements  crepitus 
will  be  most  always  perceptible  by  placing  the  ear  over  the  hip  ; the 
moment  the  extending  force  is  withdrawn  the  limb  shortens  again. 
During  these  manipulations  preternatural  mobility  at  the  seat  of  injury 
will  be  marked. 

The  shortening  will  vary  from  a few  lines  to  an  inch  and  a half, 
according  to  the  damage  done  to  the  capsular  ligament,  and  the  posi- 
tion of  the  fragments  as  regards  each  other;  for  if  these  are  impacted 
or  held  in  approximation  by  their  serrated  surfaces,  the  diminution  in 
the  length  of  the  limb  must  be  inconsiderable;  an  unruptured  capsular 
ligament  would  scarcely  permit  more  than  an  inch  shortening. 

The  decrease  in  the  length  of  the  limb  may  not  be  observed  to 
follow  the  injury  immediately,  but  three  or  four  days  may  elapse 
when  by  some  sudden  movement  of  the  patient,  turning  in  bed,  for 
instance,  the  limb  will  become  at  once  shortened.  The  most  plausible 
reason  of  this  seems  to  be  the  slipping  of  the  fragments  from  each 
other,  that  have  hitherto,  by  some  peculiarity  of  their  surfaces,  been 
held  in  contact.  In  other  instances  the  limb  gradually  shortens  within 
the  first  five  or  six  months  succeeding  the  injury. 

The  symptoms  enumerated  above  will  attend  in  almost  all  cases  of 
fracture  of  the  neck  of  the  thigh-bone;  in  those  attended  with  impac- 
tion crepitus  will  not  be  present,  unless  injudicious  movements  be 
impressed  upon  the  limb.  It  has  also  been  recorded  that  the  foot  in 
rare  instances  has  been  found  inverted. 

Prognosis. — Patients  recover  from  this  injury  in  most  cases,  but  as 

I the  union  between  the  fragments  is  rarely  ever  osseous,  unless  impac- 
tion or  an  interlocking  has  occurred,  the  functions  of  the  limb  will  be 
more  or  less  impaired ; though  under  the  worst  circumstances  the 
fibro-ligamentous  connection  that  will  be  established  between  the 
pieces  will  be  sufficiently  firm  to  enable  them  to  walk  tolerably  well. 
In  other  cases  absorption  of  the  fragments  occurs  to  such  an  extent  as 
to  render  the  limb  useless. 

Treatment. — The  treatment  of  intra-capsular  fracture  requires  the 
exercise  of  judgment  and  discrimination  in  the  selection  of  the  means 

I that  ought  to  be  employed  in  the  different  cases  of  this  injury. 

The  indications  of  treatment  are  plain,  namely,  to  bring  the  frag- 
ments into  accurate  contact,  and  to  retain  them  in  that  position  until 
the  union,  of  whatever  nature  that  may  be,  either  osseous  or  ligament- 
ous, occurs.  But  some  of  the  patients  are  old,  broken  down  in  health, 
and  very  irritable,  who  could  not  bear  the  necessary  confinement  and 
restraint  a sufficiently  long  time  to  obtain  so  desirable  a result.  In 
these  cases  the  plan  recommended  by  Sir  A.  Cooper  may  be  followed, 
which  consists  in  placing  the  patient  in  bed  with  the  fractured  limb 


440 


SPECIAL  FRACTURES. 


supported  upon  a pillow,  and  another  pillow  rolled  up  and  interposed 
between  the  knees,  keep  him  in  this  position  a fortnight  until  the 
inflammation  about  the  joint  has  subsided,  then  let  him  rise  and  sit  in 
a high  chair ; in  the  course  of  time  the  patient  will  be  enabled  to  get 
about  upon  crutches,  which,  as  the  convalescence  proceeds,  may  be 
laid  aside  for  a walking  stick. 

In  other  cases,  where  the  health  is  good  and  the  person  not  too  old, 
efforts  should  be  made  by  means  of  suitable  apparatus  to  bring  the 
fractured  ends  of  the  bone  in  contact  so  that  when  the  ligamentous 
union  does  occur  it  may  be  as  close  as  possible. 

To  carry  out  this  object  those  splints  should  be  selected  which  make 
extension  upon  the  limb,  prevent  the  eversion  of  the  foot,  and  exert 
some  pressure  upon  the  trochanter  major. 

In  the  opinion  of  Dr.  Hamilton,  splints  constructed  upon  the  prin- 
ciple of  Gibson’s  modification  of  Hagedorn’s  apparatus  are  best  calcu- 
lated to  procure  the  desired  result. 

The  manner  of  applying  this  apparatus  “ consists  in  extending  the 
patient’s  limbs  upon  a mattress,  and  confining  both  feet,  by  gaiters,  or 
a handkerchief,  to  a foot-board,  which  is  firmly  supported  upon  the 
ends  of  two  splints  passed  through  mortises  near  its  edges.  These 
splints  extend  from  the  armpit,  where  they  are  padded  like  the  head 
of  a crutch,  along  each  of  the  body,  thigh,  and  leg,  beyond  the  foot, 
and,  being  well  stuffed  on  their  inner  surfaces  to  prevent  irritation, 
are  confined  by  six  or  eight  tapes  or  bandages  passed  around  the 
limbs,  pelvis,  and  chest.”  (Fig.  370.) 


Fig.  370. 


Gibson’s  modification  of  Hagedorn's  apparatus. 


“ The  principle  upon  which  extension  and  counter-extension  are 
effected  by  this  contrivance,  will  instantly  be  understood.  The  sound 
limb  being  extended,  serves  as  a splint  to  the  broken  one.  Counter- 
extension then  is  made  upon  the  acetabulum  of  the  sound  side,  and 
extension  upon  the  ankle  of  the  injured  limb,  which,  so  long  as  the 
two  feet  are  kept  on  the  same  level,  cannot  be  shortened,  provided 
rotation  of  the  pelvis  be  prevented.  This  purpose  is  answered  by 
extending  the  splints  to  the  armpits ; and  not  with  a view,  as  might 
be  supposed,  of  producing  counter-extension  from  these  poiuts.  Find- 
ing that  the  patient,  in  the  original  machine  of  Hagedorn,  could 
incline  the  pelvis  towards  the  affected  side,  and  thereby  shorten  the 
limb,  by  causing  the  superior  fragment  to  descend  and  overlap  the 
inferior,  the  additional  splint  was  added,  and  has  been  fouud  to  answer 
completely  the  end  designed.” 


FRACTURE  OF  THE  FEMUR. 


441 


In  my  opinion,  a much  more  serviceable  and  less  cumbersome 
apparatus  is  the  one  recommended  by  Prof.  Gross.  This  distinguished 
surgeon  states  that  he  employed  it  for  the  first  time  upwards  of 
twenty  years  ago,  and  has  had  no  reason  to  abandon  its  use  since  in 
the  treatment  of  fractured  thigh.  The  apparatus  is  so  simple,  and  the 
materials  of  which  it  is  composed  so  universally  distributed,  that  the 
surgeon  can  prepare  one  in  a few  minutes  wherever  he  may  happen 
to  be.  It  consists  of  a box  made  of  some  light  wood,  extending  from 
the  tuberosity  of  the  ischium  to  the  sole  of  the  foot ; its  floor  is 
grooved,  that  it  may  more  accurately  accommodate  the  posterior  sur- 


Fig.  371. 


face  of  the  limb ; the  sides  of  the  box  are  as  deep  as  the  antero-poste- 
rior  diameter  of  the  thigh,  and  they  are  connected  by  hinges  to  its 
floor.  To  the  outer  surface  of  the  box  a movable  splint,  about  two 
inches  wide,  crutch-shaped  at  its  upper  extremity,  which  is  intended 
to  reach  as  far  as  the  axilla,  is  connected.  Another  splint,  similarly 
constructed,  is  attached  to  its  inner  side,  and  designed  to  press  against 
the  perineum ; an  ordinary  footboard,  with  two  slits  in  it,  is  placed  at 
the  lower  end  of  the  box. 

In  applying  the  apparatus  the  box  should  be  well  padded  with 
cotton  or  tow,  or,  what  is  better,  wheat  bran — especially  in  compound 
fracture,  where  there  is  much  discharge.  Two  long  strips  of  adhesive 
plaster  are  placed  upon  the  sides  of  the  leg,  and  secured  by  a third 
running  spirally ; over  this  the  turns  of  a roller  are  laid  from  the  foot 
upwards.  The  limb,  having  been  properly  extended,  is  now  put  into 
the  box,  the  inner  crutch  well  pressed  up  against  the  perineum,  and 
the  outer  one  against  the  axilla ; the  extending  strips  are  passed 
through  the  slits  in  the  footboard  and  secured  to  it,  after  the  requisite 
amount  of  extension  has  been  made.  To  render  the  foot  more  steady, 
it  may  be  further  secured  to  the  board  by  a roller  bandage.  Lastly, 
a broad  splint  of  leather  or  binders’  board  is  moulded  to  the  anterior 
surface  of  the  thigh,  reaching  from  the  groin  to  the  knee,  and  secured 
in  place  by  means  of  pieces  of  tape  encircling  the  box. 

The  principle  upon  which  this  apparatus  is  constructed  is  evident, 
the  counter  extension  is  established  at  the  perineum  and  axilla,  while 
extension  is  made  from  the  leg  by  means  of  the  adhesive  strips. 

The  long  splint,  known  as  Liston’s,  may  also  be  employed  in  this 
fracture,  but  extension  cannot  be  made  with  it  with  as  much  force 
and  regularity  as  with  the  previous  splints,  and  hence  it  is  rather 
adapted  to  those  cases  of  impacted  fracture,  in  which  little  or  no  force 


4i2 


SPECIAL  FRACTURES. 


of  the  kind  is  required,  but  the  limb  is  simply  to  be  held  at  rest 
while  the  union  is  being  effected. 

This  splint  is  made  of  deal-board,  or  other  light  wood,  of  a hand’s 
breadth  for  an  adult,  but  narrower  and  slighter  for  a child ; it  should 
be  long  enough  to  reach  from  a point  on  a level  with  the  nipple  to  a 


Fig.  372. 


point  three  or  four  inches  beyond  the  foot.  On  its  upper  end  there 
are  two  mortises,  and  at  its  lower  end  two  deep  notches,  forming 
three  teeth-like  projections;  at  the  point  corresponding  with  the  ankle 
a hole  is  to  be  made  to  accommodate  the  external  malleolus. 

The  splint  is  to  be  well  padded  with  cotton-batting,  or  layers  of 
blanket,  when  it  will  be  ready  for  use.  The  injured  limb  is  to  be 
prepared  by  bandaging  it  from  the  toes  to  the  groin;  and  while  an 
assistant  makes  extension  from  the  foot,  the  straight  splint  is  laid 
upon  its  outer  side;  the  foot  is  secured  to  it  by  the  turns  of  a roller 
passing  around  the  ankle  and  across  the  notches  in  the  lower  end  of 
the  splint,  and  the  bandage  is  then  continued  up  the  limb.  The 
counter-extending  band  is  now  passed  beneath  the  perineum,  and  its 
extremities  fastened  to  the  holes  at  the  top  of  the  splint. 

An  improved  form  of  Liston’s  splint  is  recommended  by  Mr.  Haynes 
Walton.  As  seen  in  Fig.  373,  instead  of  the  two  notches  at  the 

Fig.  373. 


Walton’s  modification  of  Liston’s  splint. 


lower  end  of  the  splint,  he  makes  two  long  slits,  by  means  of  which 
the  foot  can  be  better  secured,  by  making  the  purchase  from  the 


Fig.  374. 


Represents  the  two  slits  in  Walton’s  splint. 


FRACTURE  OF  THE  FEMUR. 


443 


ankle,  and  not  upon  the  heel  and  dorsum  of  the  foot.  This  arrange- 
ment also  tends  to  keep  the  splint  square  with  the  leg. 

In  the  treatment  of  intra-capsular  fracture  the  double-inclined  plane 
has  also  been  employed,  and  in  some  instances  reported  with  flattering 
success. 

An  apparatus  of  this  sort  may  readily  be  extemporized  after  the 
manner  recommended  by  Dupuytren,  which  is  as  follows : Take 
cushions  of  different  sizes  and  pile  them  upon  one  another  until  the 
double-inclined  plane  is  of  the  requisite  height ; upon  this  repose  the 
limb,  and  secure  it  to  the  plane  by  two  long  cravats  extending  in 
opposite  directions  across  the  thigh  and  ankle  beneath  the  cushions. 

The  most  perfect  contrivance,  perhaps,  for  intra-capsular  fracture, 
is  the  fracture-bed  of  Dr.  Daniels.  It  permits  the  limb  to  be  placed 
in  a straight  or  angular  position,  as  the  surgeon  may  require,  and  can 
be  used  in  fractures  of  one  or  both  extremities. 

The  bed  is  seen  in  Fig.  375.  A represents  a platform  of  a suitable 


Daniels’  fracture-bed. 


length  and  width,  and  supported  by  four  legs,  a.  To  the  upper  sur- 
face of  the  platform  A there  is  attached  a cross-piece,  b,  at  a short 
distance  from  the  centre,  and  directly  through  the  centre  of  the  plat- 
form there  is  made  a circular  hole  or  aperture,  c (in  dotted  lines),  said 
hole  or  aperture  having  a semicircular  cut  or  recess  in  the  cross-piece 
b.  To  the  straight  edge  of  the  cross-piece  b there  is  attached,  by 
hinges,  d,  a board,  B,  termed  the  body  plane,  the  width  of  which  may 
correspond  with  that  of  the  platform  A,  and  when  depressed  its  outer 
edge  may  be  even  with  the  edge  of  the  platform.  The  sides  of  the 
body  plane  may  be  elevated,  or  raised  so  as  to  be  slightly  concave  on 
its  outer  surface.  To  the  opposite  side  or  edge  of  the  cross-piece  b, 
and  at  each  side  of  the  semicircular  cut  or  recess  formed  by  the  hole 
or  aperture  c,  there  are  attached  by  hinges,  e,  cast-iron  plates,  C C, 
which  are  provided  with  grooves  or  ways  at  their  sides,  in  or  between 
which  plates,  B D,  work.  The  plates  G C,  D D (one  on  each  side) 


444 


SPECIAL  FRACTURES. 


are  thigh-plates,  anrl  their  edges  are  provided  with  projections,  f 
in  which  a shaft,  g,  works,  one  on  each  plate  C.  On  each  shaft  g 
there  is  placed  a pinion,  which  gears  into  a rack  attached  to  the 
under  surface  of  the  plates  D D.  At  one  end  of  the  shafts  g are 
attached  ratchets,  g',  in  which  pawls,  j,  catch,  said  pawls  being  attached 
to  the  sides  of  the  plates  C G.  To  the  outer  edges  of  the  plates 
D D are  attached  by  hinges,  k,  boards,  EE;  these  boards  are  leg 
planes,  and  are  slightly  raised  at  their  inner  ends,  where  they  are 
connected  to  the  plates  D,  in  order  to  form  depressions  to  correspond 
to  the  shape  of  the  legs.  To  the  under  surface  of  each  leg  plane  there 
is  attached  a metal  guide,  l,  in  which  a rack,  m,  works;  the  outer  ends 
of  the  racks  have  bars,  n,  projecting  from  them  at  right  angles.  To 
each  leg  plane  is  attached  a shaft,  o,  having  a pinion,  p,  and  ratchet. 
q,  thereon,  and  pawls,  r,  which  catch  into  the  ratchets  q,  the  pawls 
being  attached  to  the  outer  sides  of  the  leg  planes.  The  pinions 
gear  into  the  racks  m.  The  body  plane,  and  also  the  thigh  and  leg 
planes,  are  covered  by  a suitable  mattress,  E,  with  a hole  made 
through  it  to  correspond  with  the  hole  in  the  platform  A,  and  the 
mattress  is  slit  or  cut  to  cover  properly  the  thigh  and  leg  planes  with- 
out interfering  with  their  movements.  To  the  under  side  of  the  plat- 
form A there  is  attached  by  hinges  a flap,  F,  having  a stuffed  pad  or 
cushion,  t,  upon  it,  which,  when  the  flap  F is  secured  upwards  against 
the  platform,  fits  in  the  hole  in  the  platform  and  mattress.  The  flap 
is  secured  against  the  platform  by  a button, 

Fig.  376  represents  the  bed  with  a patient  upon  it,  having  the  ap- 
propriate dressings  and  splints  applied  for  a fractured  thigh. 


Fig.  376. 


b.  Extra-  Capsular  Fracture  of  the  Neck  of  the  Femur. — This  variety 
of  fracture  is  seen  in  Fig.  377.  The  injury  is  outside  of  the  capsule 
and  in  the  direction  of  the  intertrochanteric  line.  It  is  commonly 
accompanied  with  impaction  of  the  upper  fragment  into  the  lower, 
and  with  splitting  oft'  of  one  or  both  trochanters. 


FRACTURE  OF  THE  FEMUR. 


445 


Causes. — Falls  or  blows  upon  the 
hip  are  the  most  frequent  causes, 
though  the  fracture  may  also  result 
from  counter-stroke — the  force  being 
applied  either  to  the  knee  or  foot. 

Symptoms. — In  the  unimpacted 
varieties  of  this  injury,  the  symp- 
toms will  be  pretty  much  the  same 
as  those  observed  in  intra-capsular 
fracture.  If  the  fragments  are  held 
together  by  impaction,  of  course 
crepitus  will  not  be  perceived,  nor 
can  the  leg  be  restored  to  its  normal 
length  by  moderate  extension. 

The  following  table,  taken  from 
Dr.  Hamilton’s  excellent  Treatise  on 
Fractures  and  Dislocations,  will  ex- 
hibit at  a glance  the  chief  points  of 
difference : — • 


Fig.  377. 


SIGNS  OF  A FRACTURE  WITHIN  THE  CAPSULE. 

].  Produced  by  slight  violence. 

2.  A fall  upon  the  foot  or  knee,  or  a trip 
upon  the  carpet,  &c. 

3.  Patients  generally  over  fifty  years  of 
age. 

4.  More  frequent  in  females. 

5.  Pain,  tenderness,  and  swelling  less, 
and  deeper. 


(The  two  following  measurements 
to  be  made  from  the  anterior  superior 
spinous  process  of  the  ilium  to  the 
inner  condyle  of  the  femur.) 

6.  Shortening  at  first  less  thau  in  extra- 
capsular  fracture,  often  not  any. 

7.  Shortening  after  a few  days  or  weeks 
greater  than  in  extra-capsular  frac- 
tures; sometimes  this  takes  place 
suddenly,  as  when  the  limb  is  moved, 
or  the  patieut  steps  upon  it. 

8.  Measuring  from  the  top  of  the  tro- 
chanter to  the  inner  condyle,  or  to 
the  malleolus  internus,  the  femur  is 
not  shortened. 

9.  More  mobility  of  limb,  at  joint. 

; 10.  Trochanter  major  moves  upon  a longer 
radius. 

11.  If  the  patient  recovers  the  use  of  the 
limb,  not  restored  under  three  or  four 
months. 

12.  No  enlargement  or  apparent  expan- 
sion of  the  trochanter  major,  after 
recovery,  from  deposit  of  bony  callus. 


SIGNS  OF  A FRACTURE  WITHOUT  THE  CAPSULE. 

1.  Produced  by  greater  violence. 

2.  A fall  upon  the  trochanter  major. 

3.  Often  under  fifty  years  of  age. 

4.  Relative  frequency  in  males  and  fe- 
males not  established. 

5.  Pain,  swelling,  and  tenderness  greater 
and  more  superficial.  It  is  especially 
painful  to  press  upon  and  around  the 
trochanter. 


6.  Shortening  at  first  greater,  almost 
always  some. 

7.  Shortening  after  a few  days  or  weeks 
less  than  in  intra-capsular  fractures. 
That  is,  the  amount  of  shortening 
changes  but  little,  if  at  all  ; if  the 
impaction  continues,  not  at  all ; if  it 
does  not  continue,  it  may  shorten 
more. 

8.  Measuring  from  the  top  of  the  tro- 
chanter to  the  inner  condyle,  or  to 
the  malleolus  internus,  the  femur 
may  be  found  a little  shortened. 

9.  Less  mobility. 

10.  Trochanter  major  moves  upon  a 
shorter  radius. 

11.  If  the  patient  recovers  the  use  of  the 
limb,  restored  in  six  or  eight  weeks. 

12.  Enlargement  or  irregular  expansion 
of  trochanter,  which  may  be  felt 
sometimes  distinctly  through  the 
skin  and  muscles. 


446 


SPECIAL  FRACTURES. 


SIGNS  OF  A FRACTURE  WITHIN  THE  CAPSULE. 

13.  Progressive  wasting  of  the  limb  for 
many  months  after  recovery. 

14.  Excessive  halting,  accompanied  with 
a peculiar  motion  of  the  pelvis,  such 
as  is  exhibited  in  persons  who  walk 
with  an  artificial  limb. 


SIGNS  OF  A FRACTURE  WITHOUT  THE  CAPSULE. 

13.  The  limb  preserving  its  natural 
strength  and  size. 

14.  Slight  halt,  motions  of  the  hip 
natural. 


Prognosis. — Although  osseous  consolidation  generally  occurs  after 
extra-capsular  fracture,  yet  this  injury  should  always  be  considered 
of  a grave  character,  both  on  account  of  the  damage  done  to  the  bone 
itself,  and  the  constitutional  disturbance  it  may  involve. 

If  splitting  of  the  trochanters  complicate  the  fracture,  it  will  be  dif- 
ficult under  any  treatment  to  obtain  a favorable  result,  as  far  as  the 
utility  of  the  limb  is  concerned.  Impacted  fractures  are  less  serious 
than  those  not  so. 

Treatment. — The  treatment  of  extra-capsular  fracture  may  be  con- 
ducted with  the  apparatus  already  described,  or  with  the  contrivance 
of  Prof.  Miller,  which  consists  of  a straight  light  wooden  splint  (Fig. 
378).  “It  should  extend  from  a little  below  the  axilla,  to  a little  be- 


Fig.  378. 


yond  the  ankle,  when  the  patient  is  straight  and  recumbent;  and, 
having  been  well  padded,  more  especially  at  the  points  where  pressure 
is  likely  to  be  greatest — at  the  trochanter,  external  condyle,  and  mal- 
leolus, or  by  the  swathing  of  a broad  linen  sheet.  Then  a soft  shawl, 
or  other  suitable  band  is  pressed  beneath  the  perineum,  on  the  affected 
side ; and  has  both  its  ends  tied  on  the  upper  end  of  the  splint,  there 
being  two  holes  placed  there  for  this  purpose.” 


Fig.  379. 


Miller’s  splint  applied. 


“ A broad  bandage  or  belt  is  also  applied  firmly  round  the  pelvis, 
so  as  to  bind  the  splint  more  securely  on  the  limb,  and  keep  the  broken 
surfaces  in  apposition.  By  tightening  the  perineal  band,  from  time  to 


FRACTURE  OF  THE  FEMUR. 


447 


time,  the  splint  is  forced  downwards  ; the  splint,  having  been  made  of 
a piece  with  the  limb,  brings  the  latter  with  it.” 

c.  Fracture  of  the  Neck  of  the  Femur,  p)<*rtly  Extra- Capsular  and 
partly  Intra-  Capsular . — This  variety  of  fracture  of  the  neck  of  the 
femur  results  from  the  same  causes  that  produce  extra-capsular  frac- 
ture. 

Union  by  bone  takes  place  between  the  fragments. 

This  fracture  will  be  characterized  by  the  same  set  of  symptoms 
that  we  have  already  described  under  the  head  of  intra-capsular  frac- 
ture ; and  will  require  in  its  treatment  the  apparatus  we  have  just  now 
considered. 

d.  Fracture  of  the  Trochanter  Major. — Fracture  of  the  larger  tro- 
chanter is  commonly  found  as  a complication  of  extra-capsular  fracture, 
yet  in  rare  cases  it  has  been  detached  from  the  shaft  of  the  femur 
without  any  other  injury  to  the  bone,  the  line  of  separation  running 
downwards  and  outwards. 

In  young  subjects  an  epiphyseal  separation  has  also  been  recorded. 

The  trochanter  is  not  generally  displaced,  in  consequence  of  some 
of  the  soft  tissues  connecting  it  with  the  shaft  remaining  untorn. 

Causes. — It  may  occur  at  any  age,  though  in  the  cases  reported  it 
has  taken  place  in  old  persons  from  a blow  upon  the  hip. 

Symptoms. — The  limb  is  perfectly  helpless,  and  lies  in  an  everted 
position ; by  measurement  it  will  be  found  of  the  same  length  as  the 
opposite  one.  When  the  thigh  is  rotated  the  trochanter  does  not  par- 
ticipate in  the  motions  of  the  femur.  If  displacement  occurs,  it  will 
be  either  upwards  or  backwards,  generally  the  former ; if  the  limb  be 
abducted  and  the  trochanter  brought  down,  the  broken  surfaces  may 
be  pressed  in  contact,  and  crepitus  developed  by  rubbing  them 
together;  should  the  patient  be  in  the  erect  posture,  he  cannot  sit  down, 
from  the  extreme  pain  which  efforts  to  do  so  cause  him. 

Treatment. — Sir  A.  Cooper  recommends  the  apparatus  sketched  in 
he  annexed  wood-cut,  in  the  treatment  of  this  injury.  He  places  the 


Fig.  380. 


atient  upon  a firm  mattress,  provided  with  an  arrangement  for  using 
be  bed-pan ; at  its  lower  end  an  upright  support  is  attached,  to  which 
ie  foot  is  secured.  A broad  belt  is  made  to  encircle  the  pelvis,  so  as 
> sustain  the  trochanter  in  its  normal  position.  To  hold  the  leg  im- 
movable, after  the  application  of  the  pelvic  belt  two  lateral  splints 
ay  be  applied. 


448 


SPECIAL  FRACTURES. 


The  apparatus  should  be  continued  for  a month,  when  the  patient 
may  be  permitted  to  get  up  and  move  around. 

In  most  cases  union  by  bone  has  taken  place  promptly  without  any 
danger  being  inflicted  upon  the  functions  of  the  hip-joint. 

2.  Fracture  of  the  Shaft  of  the  Femur. — Fracture  of  the  shaft  of  the 
femur  may  occur  at  any  point  in  its  length,  but  is  most  frequent  in  its 
middle  third.  The  character  of  the  fracture  is  various,  it  may  be  sim- 
ple or  comminuted,  compound  or  complicated  with  other  injuries. 

Its  direction  is  commonly  oblique,  though 
when  it  takes  place  at  the  base  of  the  con- 
dyle, or  in  young  subjects  it  is  often  transverse. 

The  displacements  that  follow  depend  upon 
the  position  of  the  fracture;  if  this  is  towards 
the  upper  end,  the  psoas  magnus  and  ilia- 
cus  internus  will  tilt  the  upper  fragment 
forwards,  while  the  large  adductors  upon  the 
inner  side  of  the  thigh  will  draw  the  lower 
fragment  upwards  and  inwards,  behind  the 
upper,  and  at  the  same  time  will  rotate  it 
outwards. 

In  fracture  seated  about  the  middle  of  the 
femur  the  lower  fragment  will  be  displaced 
as  in  the  former  case,  but  the  upper  one  will 
rather  be  drawn  a little  outwards,  and  ride 
over  the  lower. 

Transverse  fracture  just  above  the  con- 
dyles, from  the  breadth  of  the  opposing  sur- 
faces may  not  be  attended  with  any  displace- 
ment, but  if  it  is  oblique,  the  lower  fragment 
will  be  drawn  backwards  and  downwards  by  the  gastrocnemius,  plan- 
taris,  and  popliteus. 

Symptoms. — There  is  usually  shortening  to  a considerable  extent: 
preternatural  mobility  at  the  point  of  fracture  when  the  limb  is  lifted 
from  the  bed;  the  patient  cannot  move  the  leg;  the  foot  is  everted; 
and  crepitus  will  be  developed  by  rubbing  the  fragments  against  each 
other. 

Prognosis. — Fracture  of  the  shaft  of  the  femur  is  always  a serious 
injury,  and  when  the  line  of  division  is  oblique,  it  is  almost  impossible 
by  any  apparatus  to  procure  a cure  without  some  shortening. 

Treatment.- — In  the  treatment  of  this  injury  it  is  of  great  importance 
to  procure  a suitable  mattress  upon  which  to  place  the  patient  during 
the  period  of  his  confinement.  If  it  is  possible  to  obtain  one,  a frac- 
ture-bed should  be  chosen  in  which  provision  is  made  for  all  the  re- 
quirements of  the  case. 

We  have  already  described  the  fracture-bed  of  Dr.  Daniels.  Il 
offers  many  advantages  in  conducting  the  treatment  of  fracture  of  the 
femur ; there  are  others  also  equally  as  efficient,  and  require  a passing 
notice.  The  fracture-bed  invented  by  Mr.  Jenks,  of  Providence.  Rhode 
Island,  will  be  found  ingenious  and  useful.  “It  is  composed  of  t\\\ 
upright  posts  about  six  feet  high,  supported  each  by  a pedestal — o 


Fig.  381. 


Fracture  of  the  base  of  the 
condyle. 


FRACTURE  OF  THE  FEMUR. 


449 


two  horizontal  bars,  at  the  top,  somewhat  longer  than  a common  bed- 
stead— of  a windlass  of  the  same  length  placed  six  inches  below  the 

Fig.  382. 


upper  bar— of  a cogwheel  and  handle — of  linen  belts,  from  six  to 
\ twelve  inches  wide — of  straps  secured  at  one  end  of  the  windlass,  and 
at  the  other  having  hooks  attached  to  corresponding  eyes  in  linen 
belts,  from  six  to  twelve  inches  wide — of  straps  secured  at  one  end  of 
the  windlass,  and  at  the  other  having  hooks  attached  to  corresponding 
eyes  in  the  linen  belts — of  a head-piece  made  of  netting — of  a piece  of 
sheet-iron  twelve  inches  long,  and  to  fit  and  surround  the  thigh — of  a 
bed-pan,  box,  and  cushion  to  support  it,  and  of  some  other  minor 
parts.  The  patient,  lying  on  his  mattress,  and  his  limb  surrounded 
by  the  apparatus,  the  surgeon,  or  any  common  attendant,  will  only 
find  it  requisite  to  pass  the  linen  belts  beneath  his  body  (attaching 
them  to  the  hooks  at  the  ends  of  the  straps,  and  adjusting  the  whole 
at  the  proper  distance  and  length,  so  as  to  balance  the  body  exactly), 
and  raise  it  from  the  mattress  by  turning  the  handle  of  the  windlass. 
While  the  patient  is  thus  suspended,  the  bed  can  be  made  up,  and  the 
feces  and  urine  evacuated.  To  lower  the  patient  again  and  replace 
him  on  the  mattress,  the  windlass  must  be  reversed.  The  linen  belts 
may  then  be  removed,  and  the  bodv  brought  in  contact  with  the 
•sheet.” 

A much  less  expensive  contrivance  than  Jenks’  fracture-bed  is  an 
arrangement  devised  by  Dr.  A.  Hewson,  and  described  by  him  in  the 
Am.  Journ.  Med.  Sci.,  for  July,  1858.  It  has  also  the  great  advantage 
bf  being  easily  connected  with  an  ordinary  bedstead.  As  seen  in  the 
igure,  a board  (A  B,  Fig.  883)  fifteen  or  eighteen  inches  broad,  and 
)f  sufficient  length,  is  to  be  substituted  for  three  or  four  of  the  slats 
29 


Jenks’  fracture-bed. 


450 


SPECIAL  FEACTUEES. 


forming  the  bottom  of  the  bedstead.  The  ends  of  this  board  (A  and  B) 
should  be  cut  so  as  to  fit  in  the  mortises  originally  made  in  the  sides 
of  the  bedstead  for  the  slats.  In  the  centre  of  this  board  there  should 


Fig.  383. 


be  an  oval  hole  ( C)  ten  by  seven  inches,  its  long  diameter  correspond- 
ing to  the  length  of  the  bedstead.  To  the  upper  and  lower  borders 
of  this  board  there  should  be  secured  strips,  JD  E and  F Gf  extending 
between  the  sides  of  the  bedstead.  These  strips  should  have  grooves 
near  their  lower  borders,  and  running  their  full  length,  as  seen  on  F G. 
for  the  tray  containing  the  bedpan  to  slide  in.  They  (the  strips)  should 
have  a depth  sufficient  to  make  the  plane  of  these  grooves  below  the 
plane  of  the  sides  of  the  bedstead.  To  the  bottom  of  the  board  (sub- 
stituted for  the  slats)  there  is  to  be  hinged  a trap-door.  IT,  to  which  an 
oval  and  somewhat  conical  pad  is  to  be  secured.  This  door  should 
have  a length  equal  to  a little  over  one-fourth  the  width  of  the  bed- 
stead, and  a breadth  of  twelve  inches.  It  may  be  made  of  one  inch 
stuff,  and  should  then  have  secured,  at  equal  distances  on  its  under 
surface,  two  or  three  strips  an  inch  broad,  and  with  a depth  sufficient 


FRACTURE  OF  THE  FEMUR. 


451 


to  bring  their  lower  surface  (when  the  door  is  shut  up)  on  a level  with 
the  upper  edge  of  the  grooves  in  the  side-pieces,  on  the  upper  surface 
of  the  tray.  These  strips  should  terminate  in  a cross-piece  at  the  far 
end  of  the  door,  and  this  last  piece  should  extend  an  inch  on  either  side 
beyond  the  door. 

A tray  (Fig.  384)  of  sufficient  width  to  slide  in  the  grooves  of  D E 
and  F G,  Fig.  383,  should  be  made  of  one  inch  stuff,  and  have  a length 
equal  to  five-eighths  the  width  of  the  bedstead.  This  tray  should  have 
in  it  an  oval  hole  ten  by  seven  inches  for  the  pan,  and  a square  hole 


Fig.  384. 


fully  equal  in  length  and  breadth  to  the  door,  save  at  the  end  near 
the  hole  for  the  pan ; here  this  square  opening  should  be  increased  in 
width  by  the  removal  from  either  corner  of  a piece  one  inch  by  two 
and  a half  inches,  so  as  to  allow  the  jutting  ends  of  the  cross-piece 
attached  to  the  door  to  fall  through  as  the  pan  is  pushed  towards  the 
hole  in  the  bed,  or  to  rise  up  above  the  tray  when  it  is  desired  to  re- 
move the  pan  and  replace  the  plug.  To  close  up  the  door,  and  thus 
replace  the  plug  in  the  mattress,  without  any  friction  or  jarring,  a 
wooden  roller  of  two  and  a half  inches  diameter  should  be  secured  to 
the  under  surface  of  the  tray  at  the  far  end  of  the  square  opening,  and 
at  such  a distance  from  the  notches  for  the  escape  of  the  cross-piece  of 
the  trap-door  as  will  be  equal  to  two-thirds  the  length  of  the  door. 
The  tray  is  to  be  moved  by  a handle  attached  to  it  by  a pivot. 

For  the  purpose  of  preventing  the  attendant  from  pushing  or  pull- 
ing the  tray  too  far  in  either  direction,  stops  should  be  provided,  such 
■ as  are  indicated  at  D E and  F G.  Thus  at  D E there  is  a strip  ex- 
tending between  the  cleats  which  will  check  the  tray  in  that  direction 
by  the  roller  striking  against  it.  Then  the  tray  cannot  be  drawn  out 
too  far  by  the  two  little  points  on  the  bottom  of  the  tray,  at  I and  K, 
infringing  on  the  stops  indicated  at  E and  C. 

These  last  checks  allow  of  the  tray  being  drawn  out  sufficiently  far 
from  beneath  the  bed  for  the  removal  of  the  pan,  and  when  the  tray 
is  drawn  out  this  far,  the  trap-door  is  supported  up  in  its  place  by  the 
jutting  ends  of  the  cross-piece  resting  on  the  distant  end  of  the  tray. 
These  jutting  ends  continue  to  support  the  door  as  the  tray  is  pushed 
in,  until  it  is  pushed  so  far  as  to  bring  the  notches  in  the  square 
opening  beneath  these  ends,  when  all  support  is  removed  from  the 
door,  and  it  falls  rapidly  by  its  own  weight;  then,  by  continuing  to 


452 


SPECIAL  FRACTURES. 


push  the  tray  inwards,  the  pan  is  brought  beneath  the  opening  in 
the  bed. 

A hole  should  be  made  in  the  mattress  to  correspond  with  that  in 
the  board.  It  should  be  oval,  and  measure  ten  by  six  inches  on  the 
upper  surface.  The  far  side  of  this  hole  (from  the  hinges  of  the  doorj 
should  be  bevelled,  so  that  it  will  measure  in  the  lower  surface  ten  by 
seven  inches.  To  prevent  the  weight  of  the  patient  pressing  the  mat- 
tress over  into  this  opening,  the  edge  of  the  hole  in  the  board  should 
be  bound  round  with  tin,  jutting  an  inch  and  a half  above  its  upper 
surface. 

The  apparatus  will  work  best  when  the  hinges  of  the  door  are  as 
far  as  possible  from  the  hole,  and  the  plug  placed  as  near  as  it  can  be 
to  the  free  end  of  the  door.  The  plug  will  thus  be  made  to  describe 
the  arc  of  the  largest  circle  possible  in  the  swinging  of  the  door,  and 
will  therefore  not  require  to  be  bevelled  as  much  as  it  would  if  placed 
in  the  centre  of  the  door,  and  the  door  hinged  nearer  to  the  opening. 
The  bevelling  of  the  plug  and  of  the  hole  in  the  mattress  is  only 
required  on  one  side — the  side  towards  the  handle  of  the  tray — and  if 
this  bevelling  is  made  to  correspond  with  the  arc  of  the  circle  de- 
scribed by  the  upper  and  far  edge  of  the  plug,  the  plug  will  fit  with 
great  accuracy  in  the  opening.  This  plug  should  be  secured  firmly 
to  the  door,  either  by  being  tacked  to  it  or  fastened  by  tapes  passed 
through  holes  provided  for  the  purpose. 

When  these  more  convenient  and  perfect  apparatus  are  not  attain- 
able, the  surgeon  can  extemporize  a simple  arrangement,  by  means  of 
which  the  patient’s  position  need  not  be  disturbed  in  using  the  bed- 
pan  or  changing  the  bedclothes.  It  is  thus  prepared:  Upon  the  mat- 
tress intended  to  be  lain  on  by  the  patient,  a piece  of  stout  canvas  is 
spread,  and  kept  stretched  by  being  nailed  or  sewed  to  an  ordinary 
cot  frame.  In  its  centre,  corresponding  to  the  nates,  a hole  is  cut. 
Two  sheets  are  doubled  and  placed  over  the  canvas,  with  their  folded 
margins  meeting  at  the  hole.  The  sheets  and  frame  should  lie 
smoothly  upon  the  mattress,  that  no  inequalities  be  presented  beneath 
the  patient  to  hurt  his  skin.  When  it  is  necessary  to  use  the  bed- 
pan,  all  that  is  necessary  is  to  raise  the  patient  from  the  mattress  with 
the  cot  frame,  and  support  it  by  four  blocks  placed  under  its  corners; 
or,  what  I always  use,  a rope  attached  to  the  two  ends  of  the  frame, 
and  running  over  the  cross-pieces  of  the  bedposts.  The  pan  may  then 
be  shoved  beneath  him,  the  folded  edges  of  the  sheets  having  been 
previously  turned  aside. 

When  tbe  surgeon  has  selected  and  prepared  his  bed,  he  is  then 
to  apply  his  splints,  of  which  there  are  a great  variety  employed  in 
the  treatment  of  fracture  of  the  shaft  of  the  femur.  Some  surgeons 
employ,  in  all  cases,  splints  that  maintain  the  limb  in  an  angular 
position;  others,  those  that  keep  it  straight;  while  a third  class  use 
both  kinds — the  angular,  in  fractures  of  the  upper  and  lower  ends  of 
the  femur,  and  straight  splints  in  fracture  of  its  middle  portion. 

Mr.  Pott  was  the  first  to  bring  into  notice,  and  cause  to  be  adopted, 
the  treatment  of  fracture  of  the  thigh  with  the  limb  in  a bent  posture. 
His  object  was  to  relax  those  muscles  which  he  believed  to  be  the 


FRACTURE  OF  THE  FEMUR. 


453 


principal  agents  in  deranging  tlie  fragments  by  tbeir  contraction. 
The  fact  did  not  seem  to  occur  to  Mr.  Pott  that,  in  thus  relaxing  one 
set  of  muscles,  he  must  necessarily  put  those  opposing  them  in  a pro- 
portional degree  of  extension.  However,  the  principal  objections  to 
Pott’s  plan  are,  that  the  limb  is  not  properly  secured,  and  therefore  is 
constantly  liable  to  be  disturbed,  and  the  fragments  displaced;  and 
that  the  weight  of  the  body  is  sustained  upon  the  trochanter  of  the 
injured  side  for  too  prolonged  a period  to  escape  injury.  I have 
employed  the  method  with  advantage  in  certain  cases  of  gunshot 
fracture,  with  laceration  of  the  soft  tissues. 

Mr.  Pott  directs  that  “ the  position  of  the  fractured  os  femoris  should 
be  on  its  outside,  resting  on  the  great  trochanter ; the  patient’s  whole 
body  should  be  inclined  to  the  same  side ; the  knee  should  be  in  a 
middle  state,  between  perfect  flexion  and  extension,  or  half  bent ; the 
foot  and  leg  lying  on  their  outside  also,  should  be  well  supported  by 
smooth  pillows,  and  should  be  rather  higher  in  their  level  than  the 
thigh ; one  very  broad  splint  of  deal,  hollowed  out,  and  well  covered 
with  wool,  rag,  or  tow,  should  be  placed  under  the  thigh,  from  above 
the  trochanter,  quite  below  the  knee ; and  another,  somewhat  shorter, 
should  extend  from  the  groin  below  the  knee  on  the  inside,  or  rather 
in  this  posture  on  the  upper  side ; the  bandage  should  be  of  the 
eighteen-tail  kind ; and  when  the  bone  has  been  set,  and  the  thigh 
well  placed  on  the  pillow,  it  should  not,  without  necessity  (which 
necessity  in  this  method  will  seldom  occur),  be  ever  moved  from  it 
again  until  the  fracture  is  united ; and  this  union  will  always  be 
accomplished  in  more  or  less  time  in  proportion  as  the  limb  shall 
have  been  more  or  less  disturbed.” 

To  obviate  the  objections  to  Pott’s  plan  Sir  C.  Bell  recommended  a 
modification  of  the  bent  posture,  the  peculiarity  of  his  method  con- 
sisting in  supporting  the  limb  upon  a double-inclined  plane,  the  patient 
lying  upon  his  back.  The  plane  was  constructed  of  two  boards  ten 
or  eleven  inches  wide,  joined  together  at  such  an  angle  under  the 
popliteal  space  that  the  hip  and  knee-joints  should  be  slightly  bent. 
A cushion  was  laid  over  the  frame,  and  in  order  to  give  support  and 
steadiness  to  the  limb  and  prevent  the  lateral  inclination  of  the  foot, 
a number  of  holes  were  bored  in  the  margins  of  the  boards  to  receive 
wooden  pins,  which  held  the  sides  of  the  cushion  against  the  leg. 
When  the  fracture  was  reduced  and  the  limb  placed  upon  this  appa- 
ratus, two  splints  were  secured  to  the  sides  of  the  thigh  by  an  eighteen- 
tail  bandage. 

Many  modifications  of  this  apparatus  of  Bell  have  been  employed 
since.  The  one  seen  in  Fig.  385  was  used  at  the  Middlesex  Hospital, 
London,  according  to  Mr.  Lonsdale,  in  1838. 

It  differs  from  the  preceding  one  in  having  a horizontal  board 
attached  by  one  extremity  to  the  upper  end  of  the  thigh-plate,  while 
the  other  extremity  of  the  board  supported  the  lower  end  of  the  leg- 
plate  upon  a number  of  notches,  which  enabled  the  surgeon  to  vary 
the  angle  according  to  his  pleasure.  The  thigh-piece,  which  is  hinged 
to  the  leg-plate,  consists  of  two  pieces  instead  of  one,  so  that  it  may 
be  adapted  to  limbs  of  different  lengths. 


454 


SPECIAL  FRACTURES. 


In  applying  the  apparatus  it  is  recommended  to  pad  it  with  flannel 
so  as  to  make  a smooth  and  uniform  bed  upon  which  to  lay  the  limb, 


Fig.  385. 


and  then  to  secure  to  the  front  and  sides  of  the  thigh  three  splints  with 
an  eighteen-tail  bandage.  The  foot  is  fastened  to  an  upright  support 
by  the  turn  of  a roller,  which  is  to  be  continued  upwards ; to  finish,  the 
pegs  are  inserted  into  the  holes  along  the  sides  of  the  boards.  Fig. 

Fig.  386. 


A 


386  shows  the  apparatus  applied;  the  lines  A and  B indicate  the  proper 
positions  that  the  angle  of  the  frame  and  the  upper  end  of  the  hori- 
zontal board  should  occupy. 

In  using  the  double-inclined  plane,  the  weight  of  the  body  is  made 
to  serve  the  purpose  of  a counter-extending  force,  and  thus  drawing 
upon  the  foot  attached  to  the  upright  support  establishes  the  extension, 
which  certainly  cannot  thus  be  accomplished  with  any  uniformity  or  to 
any  great  extent.  From  the  fact  of  the  pelvis  not  being  in  any  manner 
connected  with  or  controlled  by  the  apparatus,  it  is  at  liberty  to  move 
in  any  direction,  and  will  displace  the  upper  fragment.  In  employing 
the  apparatus,  it  will  be  found  necessary  to  attempt  to  obviate  this 
obstacle,  and  also  to  prevent  the  loss  of  contiguity  of  the  two  frag- 
ments by  lateral  deflection  of  the  upper  one,  bv  shifting  the  position 
of  the  double-inclined  plane,  bringing  it  towards  or  removing  it  from 
the  sound  limb,  according  to  circumstances. 

Mr.  Amesbury  endeavored  to  fix  the  pelvis  by  the  apparatus  seen 


FRACTURE  OF  THE  FEMUR. 


455 


in  Fig.  387.  It  consists  of  three  portions,  one  (a)  for  the  thigh, 
another  (b)  for  the  leg,  and  a third  (c)  for  the  foot.  To  each  apparatus 

Fig.  387. 


there  are  two  thigh-pieces,  one  bevelled  to  the  right  at  the  lower  end, 
and  the  other  to  the  left,  one  or  the  other  being  used  in  connection 
with  the  leg-piece,  according  as  the  apparatus  is  to  be  applied  to  the 
right  or  left  extremity — for  the  reason  that  a perfectly  formed  limb  is 
not  straight,  but  turns  inwards  at  the  knee.  The  thigh  and  leg  por- 
tions are  connected  together  by  a joint,  which  is  controlled  by  a steel 
rod  (e)  attached  by  one  end  to  the  back  of  the  leg- piece,  and  at  the 
other  moves  in  a rack  placed  upon  the  posterior  surface  of  the  thigh- 
piece,  to  which  it  can  be  secured  at  different  points  with  a little  pin ; 
this  arrangement  allows  the  angle  of  the  plane  to  be  varied  at  pleasure. 
To  the  upper  part  of  the  thigh-piece  there  is  a sliding  plate  which 
permits  this  piece  to  be  adapted  to  limbs  of  different  lengths;  the 
plate  itself  is  turned  off  at  its  upper  edge  so  that,  when  properly 
padded,  it  may  press  against  the  tuberosity  of  the  ischium  without 
damaging  the  skin ; it  also  has  soldered  to  its  back  two  bars,  under 
which  the  pelvic  strap  passes.  The  pelvic  strap  is  made  of  leather 
with  a sliding  pad  upon  it. 

In  the  application  of  the  apparatus  it  should  be  first  well  padded 
(Fig.  388) ; a roller  bandage  is  then  placed  upon  the  leg  from  the 


Fig.  388. 


The  same  applied. 


toes  to  the  knee,  and  the  limb  placed  upon  the  plane ; the  foot  is  in- 
closed in  the  shoe  (a),  supported  by  the  footboard,  nearly  at  right 
angles  with  the  leg-piece ; inequalities  beneath  the  limb  are  corrected 
by  stuffing  between  it  and  the  splint  cotton  or  tow.  The  leg  is 
secured  to  the  apparatus  by  the  turns  of  a roller  bandage  reaching 
from  the  ankle  to  the  knee.  An  assistant  now  makes  extension  by 


456 


SPECIAL  FRACTURES. 


seizing  the  knee  while  the  surgeon  coaptates  the  fragments  and  then 
applies  the  splint,  the  first  to  the  outer  side  of  the  limb,  the  second 
upon  its  inner  side,  and  the  third  upon  the  front  part  of  the  thigh ; 
the  splints  are  held  in  place  by  the  straps.  The  pelvic  strap  is  now 
carried  around  the  thigh,  and  made  to  cross  on  the  outer  side,  while 
the  buckle-end,  with  the  sliding  pad,  is  carried  around  the  pelvis  and 
made  to  meet  the  other  end  in  front,  where  they  are  fastened  together. 
The  lower  part  of  the  apparatus  is  fixed  to  the  foot  of  the  bed  by  the 
tapes. 

Dr.  J.  C.  Nott  has  also  devised  a double-inclined  plane,  which  differs 
very  little  from  the  one  described  by  Mr.  Lonsdale.  The'  tuberosity 


Fig.  389. 


of  the  ischium  rests  upon  the  upper  end  of  the  thigh-piece;  the  thigh 
has  two  splints  upon  its  sides,  secured  by  buckles  and  straps,  and  so 
has  the  leg;  the  horizontal  board  consists  of  a single  piece  notched  at 
its  far  end. 

The  inclined  plane  is  also  used  by  surgeons  in  the  treatment  of 
fractured  thigh,  suspended  from  the  ceiling,  or  the  top  of  the  bed- 
stead. It  maintains  the  leg  in  the  flexed  position,  and  at  the  same 
time  allows  it  to  move  laterally,  or  to  participate  wfith  the  trunk  in 
any  of  its  movements.  The  suspension  plan  is  of  real  service,  and  I 
know  of  nothing  superior  to  it  in  certain  cases  of  compound  fracture 
of  the  thigh,  with  laceration  of  the  soft  parts;  and  during  the  late  war 
the  anterior  splint  of  Prof.  N.  R.  Smith,  of  Baltimore,  was  deservedly 
held  in  high  esteem  by  military  surgeons  in  such  cases. 

Mayor’s  apparatus  for  fractured  thigh  consists  of  a wire  frame,  with 
a thigh  and  leg-piece  fastened  together  at  an  angle  which  may  be 
varied  by  the  tension  of  a chain  passing  from  the  cross-bar  at  the 
upper  end  of  the  frame  to  the  top  of  the  bent  section  of  the  leg-piece, 
which  is  made  to  answer  the  purpose  of  a foot-board. 

Upon  this  frame  a cushion  is  placed,  on  which  the  limb  is  laid  and 
secured  by  three  cravats  passing  around  the  thigh,  leg,  and  foot.  A 
fourth  cravat  encircles  the  hips  and  upper  part  of  the  thigh,  having 
its  ends  attached  to  the  thigh-piece  upon  both  sides;  this  secures  the 
apparatus  to  the  pelvis.  The  frame  is  now  slung,  by  means  of  cords 
connected  with  the  upper  and  lower  corners  of  the  leg  section,  from 
the  ceiling  or  top  of  the  bedstead. 


FRACTUKE  OF  THE  FEMUR. 


457 


The  double-inclined  plane  of  Prof.  Smith  (Fig.  390)  is  slung  with 
cords  in  the  same  manner,  but  the  apparatus  is  constructed  with  two 


Fig.  390. 


lateral  iron  bars,  jointed  at  their  middle,  and  extending  from  the  hip 
to  the  foot.  The  upper  sections  of  these  bars,  corresponding  with  the 
thigh,  are  joined  together  by  a metallic  trough ; the  leg  is  supported 
by  broad  bands  of  webbing,  passing  between  the  bars  of  the  lower  sec- 
tions, to  the  far  end  of  which  a footboard  is  attached.  At  the  top  of 
the  outer  bar  a curved  metal  stem  is  placed  bearing  the  pelvic  strap. 

In  applying  this  apparatus,  it  is  first  to  be  padded  with  flannel 
or  cotton-batting.  The  limb  is  now  raised  and  extended  by  an  as- 
sistant, while  the  surgeon  places  the  frame  beneath  it  and  secures  the 
foot  to  its  board  by  a roller  bandage ; the  leg-bands  are  fastened, 
and  a broad  splint,  laid  upon  the  anterior  surface  of  the  thigh,  is 
secured  by  straps.  The  pelvic  strap  is  passed  round  the  hips,  and 
buckled ; and  lastly,  the  apparatus  is  suspended  by  a cord  from  the 
ceiling. 

The  “anterior  splint”  of  the  same  distinguished  surgeon  is  formed 
of  wood  or  wire,  the  latter  being  preferable.  It  is  intended  to  be 
applied  to  the  anterior  plane  of  the  limb,  and  slung  from  the  ceiling. 


Fig.  391. 


N.  E.  Smith’s  anterior  splint. 


The  wire  splint  (Fig.  391)  may  be  prepared  by  the  surgeon  in  a few 
ninutes,  whenever  wire  is  attainable,  of  which  Nos.  8 or  9 will  answer 
he  purpose;  of  this  a piece  is  taken  of  sufficient  length,  when  doubled 
ind  bent  to  the  limb,  to  reach  from  the  anterior-superior  spinous  pro- 
cess to  a point  two  inches  beyond  the  toes.  The  two  sides  of  this  are 
low  expanded  so  as  to  be  as  broad  as  the  limb;  that  is,  wide  above, 
nd  gradually  tapering  to  the  toes.  To  retain  this  form,  cross-pieces 
>f  a smaller  sized  wire  are  connected  with  them;  two  of  these  cross 


458 


SPECIAL  FRACTURES. 


wires,  one  over  tire  thigh  and  the  other  over  the  leg,  have  an  eye 
worked  in  at  their  centres  for  the  attachment  of  the  suspending  cord. 

The  wire  frame  thus  prepared  is  bent  at  the  groin,  knee,  and  ankle, 
so  as  to  lie  in  exact  contact  with  the  anterior  plane  of  the  limb,  which 
is  to  be  slightly  flexed. 

The  splint  is  now  enveloped  in  a layer  of  cotton  batting,  and  encir- 
cled with  a roller  bandage  and  laid  upon  the  limb.  Three  or  four 
strips  of  adhesive  plaster  are  applied  round  both  splint  and  limb,  at 
the  sole  of  the  foot,  middle  of  leg,  and  thigh.  These  will  support  the 
parts,  while  the  surgeon  applies  a roller  bandage  from  the  toes  upwards. 
Arriving  at  the  pelvis,  a spica  of  the  hip  should  be  formed  with  the 
roller.  When  this  is  finished,  the  apparatus  is  to  be  slung  from  the 
ceiling  by  a cord,  to  which  a certain  degree  of  obliquity  is  to  be  given. 
(Fig.  392.) 


Fig.  392. 


The  obliquity  of  the  cord,  and  the  application  of  the  splint  upon  the 
anterior  surface  of  the  limb,  are  the  peculiarities  of  Dr.  Smith’s  appa- 
ratus. It  is  by  the  first  that  extension  is  made,  which  will,  of  course, 
vary  in  intensity  with  the  degree  of  this  obliquity.  The  cord,  in  this 
position,  is  constantly  pulling  the  patient  towards  the  foot  of  the  bed, 
while  the  only  resistance  offered  is  by  the  weight  of  the  body,  which 
forms,  therefore,  the  counter-extending  force. 

In  compound  fractures,  resulting  from  gunshot,  attended  with  lace- 
ration of  the  soft  parts,  I have  employed  this  splint  a number  of 
times  with  the  most  decided  advantage,  and  I think,  under  such  cir- 
cumstances, it  has  given  more  relief  to  the  patient  than  any  other  con- 
trivance I am  acquainted  with  could  have  done.  It  facilitates  the 
dressing  and  cleansing  of  the  parts,  does  away  with  the  constant  dis- 
turbance of  the  limb  for  these  purposes,  and  supports  it  in  such  a 
manner  that  it  may  be  moved  about  with  facility  in  a horizontal  plane, 
permitting  also  the  position  of  the  patient  to  be  changed  without  dis- 
turbing the  limb. 


FRACTURE  OF  THE  FEMUR. 


459 


Dr.  James  Palmer,  U.  S.  1ST.,  has  modified  the  “anterior  splint”  for 
double  fracture,  as  seen  in  Fig.  393,  and  described  in  the  Amer.  Journ. 
Med.  Sciences,  No.  99,  for  1865.  It  consists  of  two-  continuous  parallel 
rods  of  No.  9 iron  wire,  passing  over  the  anterior  surfaces  of  both 
limbs  from  the  toes  upwards,  arching  over  the  pubes  clear  of  the  ante- 
rior spinous  processes,  and  bent  at  the  groins  at  an  angle  of  about 
thirty  degrees.  The  abdominal  arch  was  well  padded,  and  the  whole 
apparatus,  enveloped  with  roller  bandages,  as  usual,  was  first  secured 
to  the  pelvis,  a trough  of  binder’s  boards  being  accurately  moulded 
to  the  back  of  each  thigh  ; bandages  from  the  toes  upwards  were  next 
applied  around  each  limb,  including  the  splint,  and  when  they  reached 
the  groins  were  secured  to  the  arch  on  each  side,  and  the  ends,  finally 
carried  over  the  mattress,  clear  of  the  patient’s  body,  were  made  fast 
to  the  head  of  the  iron  bedstead,  the  weight  of  the  body  making  the 
counter-extension.  Lastly,  the  limbs,  separately  slung,  were  suspended 
by  a single  cord  passing  over  a pulley  at  the  ceiling,  and  making- 
extension  at  an  angle  of  about  thirty  degrees,  as  seen  in  Fig.  393. 


Fig.  393. 


Palmer’s  modification  of  the  anterior  splint. 


Dr.  Palmer  suggests  an  improvement  upon  this  by  bending  the  wires 
outwards  and  downwards  at  the  instep,  and  carrying  them  out  parallel 


460 


SPECIAL  FRACTURES. 


with  the  soles  of  the  feet,  so  as  to  secure  to  their  ends  a copper  trough, 
to  which  the  patient’s  own  shoes  may  be  attached  for  support  at  the 
heels. 

Although  there  are  certain  cases  in  which  it  would  be  advisable 
to  treat  fracture  of  the  thigh  in  the  bent  position,  yet  as  a general 
method  the  straight  position  should  be  preferred.  We  have  already 
indicated  above  the  instances  in  which  this  preference  should  be  exer- 
cised, viz.,  fractures  just  below  the  trochanter  minor,  in  which  the 
upper  fragment  is  tilted  upwards  and  somewhat  outwards,  and  at  the 
base  of  the  condyles,  the  inferior  fragment  being  acted  upon  by  the 
muscles  of  the  calf  of  the  leg,  and  drawn  backwards.  In  the  first  in- 
stance, by  bending  the  thigh  upon  the  pelvis,  the  psoas  magnus  and 
iliacus  are  relaxed,  and  the  fragment  into  which  they  are  inserted 
permitted  to  descend  in  line  with  the  axis  of  the  rest  of  the  bone; 
and  in  the  second,  the  flexion  of  the  knee  relaxes  the  muscles  of  the 
calf,  which  displace  the  lower  fragment  backwards. 

This  method  of  treatment  was  particularly  recommended  by  De- 
sault, and  is  generally  adopted  by  American  surgeons.  The  parts  of 
this  surgeon’s  apparatus  are : 1st.  Three  splints,  each  one  and  a half 
inch  wide,  a long  one  to  extend  from  the  crest  of  the  ilium  to  a point 
four  inches  beyond  the  foot,  intended  for  the  external  surface  of  the 
limb ; its  ends  are  concave,  and  mortised ; a second  splint,  somewhat 
shorter,  for  the  inner  surface  of  the  limb,  extending  from  the  perineum 
to  the  sole  of  the  foot ; a third  short  splint,  reaching  from  the  fold  of 
the  groin  to  the  knee.  2d.  Three  cushions  filled  with  bran  or  oat 
chaff.  3d.  A bandage  of  Scultetus,  the  strips  of  which  are  long 
enough  to  reach  twice  around  the  limb,  overlapping  each  other  about 
one-third  of  their  breadth,  and  variable  as  to  number,  ascending  to  the 
requirements  of  the  case.  4th.  Two  oblong  compresses.  5th.  Two 
strong  strips  of  bandage  for  extension  and  counter-extension.  6th. 
A splint-cloth  and  body  bandage. 

The  apparatus  is  applied  by  spreading  upon  the  bed  the  splint-cloth, 
which  may  be  a piece  of  stout  muslin,  two  yards  long  and  as  wide  as 
the  inner  splint;  upon  this  the  bandage  of  Scultetus  is  placed,  reach- 
ing from  the  ankle  to  the  hip.  The  limb  having  been  laid  on  the 
centre  of  the  bandage,  extension  is  made  from  the  leg,  and  the  sur- 
geon, having  coaptated  the  fragment,  puts  one  of  the  oblong  compresses 
along  the  anterior  surface  of  the  thigh,  and  then  applies  the  bandage 
of  Scultetus ; the  ankle  is  padded  with  tow,  or  inclosed  in  a compress, 
and  the  extending  band  is  applied  ; the  three  cushions  are  next  putin 
position,  and  the  lateral  splints  rolled  up  in  the  splint-cloth  from  its 
edges  against  the  limb,  so  as  to  compress  it  uniformly;  the  third  splint 
is  pfaced  on  the  thigh.  Five  strong  bands  are  now  fastened  around 
the  limb  to  secure  the  apparatus.  The  extending  and  counter-extend- 
ing bands  are  passed  through  the  mortises,  and  tied  over  the  ends  of 
the  long  splint;  the  upper  extremity  of  this  splint  is  bound  to  the 
side  of  the  pelvis  by  a broad  bandage.  Any  tendency  to  lateral  devia- 
tion of  the  foot  is  prevented  by  passing  a strip  of  bandage  about  it, 
and  pinning  it  by  its  ends  to  the  splint-cloth. 

The  objection  to  the  apparatus  of  Desault  is,  that  the  extending  and 


FRACTURE  OF  THE  FEMUR. 


461 


Fig.  394. 


counter-extending  forces  do  not  act  in  the  line  of  the  axis  of  the 
broken  limb,  but  obliquely,  so  that  the  perineal  band  is  constantly 
disposed  to  draw  the  upper  fragment  outwards. 

To  obviate  this  Dr.  Physick  modified  Desault’s  long  splint  by  ex- 
tending it  up  to  the  axilla,  so  as  to  bring  the  line  of  traction  of  the 
perineal  band  in  the  direction  of  the  axis  of  the  broken  leg ; 
he  also  observed  that  the  extending  band  drawing  with  much 
force  pulled  the  foot  against  the  lower  end  of  the  splint  and 
bent  the  ankle,  and  suggested  to  Dr.  Hutchinson  to  have  re- 
course to  some  expedient  to  correct  the  oblique  traction ; the 
latter  gentleman  then  adopted  the  notched  block  nailed  to 
the  lower  end  of  the  splint,  as  seen  in  Fig.  394.  This  splint 
is  otherwise  like  that  of  Desault’s,  and  is  applied  in  the  same 
manner. 

The  next  apparatus  that  has  enjoyed  the  confidence  of 
many  of  the  continental  surgeons  is  that  of  Boyer.  It 
.consists  of  an  external  long  splint  (Fig.  395),  reaching  from 

Fig.  395. 


Boyer’s  apparatus. 

he  hip  to  beyond  the  sole  of  the  foot ; its  upper  end  is 
ittached  to  the  outer  side  of  the  counter-extending  band, 
vhile  the  lower  one  is  peculiarly  constructed,  by  having  a 
enestrum  cut  into  it,  through  which  a long  screw  moves  by 
l crank.  The  screw  supports  a plate  to  which  the  foot- 
board is  attached,  and  confers  upon  the  latter  a certain 
ange  of  vertical  motion.  There  are  two  other  splints  for 
he  inner  and  anterior  surfaces  of  limb.  The  lower  end  of 
he  apparatus  is  supported  upon  the  mattress  by  two  pro- 
3Cting  stems  attached  to  the  footboard. 

The  splints  are  cushioned  and  applied  in  the  same  manner 
s the  apparatus  of  Desault,  already  mentioned. 

The  peculiarity  of  Boyer’s  splint  consists  in  the  manner 
f making  extension  by  fastening  the  foot  to  an  upright 
apport  moved  by  a screw. 

An  apparatus  constructed  by  Dr.  Alonzo  Chapin  is  seen  in  Fig.  396. 
'he  long  splint  (1)  has  four  holes  at  its  upper  extremity,  and  three 
rnons  at  its  lower,  the  latter  corresponding  with  an  equal  number  of 
mons  in  the  distal  end  of  the  inside  splint  are  intended  to  support  a 
'ansverse  bar.  Through  the  bar  two  holes  are  pierced  for  two  hooked 
crews  to  work  in ; the  screws  are  moved  by  nuts  abutting  against 
ie  outer  side  of  the  bar,  and  when  the  splint  is  applied  the  extending 
ands  are  hooked  to  the  screws.  The  inside  splint  is  concave  at  its 
roximal  end  and  perforated  with  two  holes  through  which  the 


Physick’ s 
splint. 


462 


SPECIAL  FRACTURES. 


counter-extending  band  passes  and  presses  the  splint  against  the 
perineum.  The  apparatus  is  applied  in  the  usual  manner  to  the  limb 

Fig.  396. 

Jo-o  " — , 

o o □ □ □ 1 


Chapin’s  apparatus. 


protected  with  cushions.  Should  occasion  require,  the  splints  maybe 
drawn  asunder  and  the  limb  examined  without  disturbing  it. 

This  peculiarity  of  the  counter-extending  band,  acting  upon  the 
perineum  by  pressing  the  upper  end  of  the  inside  splint  against  it.  is 
also  seen  in  the  apparatus  (Fig.  397)  of  Prof.  W.  E.  Horner,  which 


Fig.  397. 


Horner's  apparatus. 


has,  besides,  the  cushions  immovably  fixed  to  their  inner  surfaces 
The  end  of  the  splint  is  notched,  and  spanned  with  a leathern  strap 
while  the  perineal  band  is  attached  below  by  passing  under  twc 
leathern  loops. 

Dr.  Joseph  E.  Hartshorne  does  away  with  the  perineal  band  fo 
counter-extension  altogether,  and  in  his  apparatus,  shown  in  tb 
annexed  drawing  (Fig.  398),  pads  the  upper  end  of  the  inside  splin 


Fig.  39S. 


to  press  against  the  perineum  and  make  counter-extension.  The  tv- 
splints  are  connected  below  by  two  cross-pieces  supporting  a woode 
screw,  which  moves  the  footboard.  The  splints  may  be  separate 
from  eadh  other,  and  the  long  splint  removed  if  the  necessities  of  tb 
case  should  demand. 


FRACTURE  OF  THE  FEMUR. 


468 


Drs.  Burges  have  constructed  an  ingenious  fracture  apparatus, 
sketched  in  the  following  drawings  (Figs.  399,  400),  in  which,  to  ob- 


Fig.  399. 


Burges’  apparatus. 


Fig.  400. 


The  same  applied. 

j 

viate  the  injurious  effects  of  pressure  of  the  counter-extending  band 
upon  the  perineum,  they  have  transferred  the  resistance,  in  a measure, 
i to  the  tuberosity  of  the  ischium. 

The  apparatus  consists  of : “ A,  thick  mattress.  B,  thin  mattress. 
C,  wooden  platform  upon  which  the  thin  mattress  is  laid.  This  plat- 
form is  made  in  two  pieces,  and  hinged  together  so  as  to  fold  upon 
"itself  for  convenience  of  transportation,  and  when  in  use  is  merely 
hooked  upon  the  central  platform  D. 

“D,  central  or  cushioned  platform  supported  at  either  end  by  wooden 
strips  marked  E,  which  rest  upon  F,  a second  platform  of  same 
extent  as  D.  This  constitutes  a shelf  for  the  bed-pan,  which  may  be 
introduced  below  ffom  either  side. 

“ G,  hair  cushion,  upon  which  the  hips  of  the  patient  rest.  This 
.'cushion,  as  well  as  the  platform  D,  to  which  it  is  buttoned,  has  a 
semicircular'  opening  at  its  lower  margin  for  convenience  of  defecation. 

“3,  a rectangular  wooden  slide,  exactly  corresponding  to  its  fellow 
upon  the  opposite  side  of  the  pelvis.  These  slides  are  so  arranged 
upon  the  platform  D as  to  be  separated  or  approximated  at  will,  and, 
by  a thumb-screw  which  passes  through  a fissure  in  the  horizontal 
portion  of  each,  they  may  be  fixed  at  the  desired  point  so  as  exactly 


464 


SPECIAL  FEACTUBES. 


to  embrace  tbe  pelvis  of  any  patient.  There  is  also  a fissure  in  the 
perpendicular  position  of  each  rectangular  slide,  and  a screw  passing 
through  the  same.  One  of  these  is  to  secure  the  upper  end  of  the  long 
splint  J , and  the  other  for  the  attachment  of  a short  splint  I,  upon 
the  side  of  the  pelvis,  corresponding  to  the  uninjured  limb.  Both 
of  these  splints  are  well  padded  upon  one  surface,  and  may  be  elevated 
or  depressed  at  will,  in  order  to  bring  them  to  the  level  of  the  limb 
and  fixed  at  the  proper  altitude  by  the  screws  already  mentioned. 
They  are  also  mutually  transferable,  thus  adapting  the  apparatus  to 
fractures  of  either  thigh. 

“SS,  counter-extending  pads.  These  are  attached  by  leather  straps 
to  the  upper  surface  of  the  platform  D,  about  twelve  inches  apart. 

Passing  under  the  cushion  G,  and  becoming  well-rounded 
Fig.  401.  pads,  they  traverse  the  tuberosities  of  the  ischia,  pass 
between  the  thighs,  and  thence  perpendicularly  to  the 
horizontal  iron  rod  or  crossbar  L.  The  crossbar  L is 
supported  at  each  end  by  a perpendicular  bar  extending 
upwards  from  tbe  platform  D.  Attached  by  one  ex- 
tremity to  the  crossbar  X is  a rod  P,  running  parallel 
with  and  situated  directly  above  the  thigh.  The  other 
end  of  this  rod  P is  supported  by  an  arched  iron  bar 
N,  extending  upwards  from  the  outer  side  of  the  long 
splint  J.  The  rod  P is  designed  to  afford  special  sup- 
port to  the  injured  limb  whenever  such  support  is 
deemed  advisable.  Two  or  three  strips  of  cotton  cloth,  of 
suitable  width,  may  be  passed  around  the  limb,  either  in- 
ternally or  externally  to  the  splints  of  coaptation,  and 
tied  over  the  supporting  rod  P.  Splints  of  coaptation 
are  to  be  applied  according  to  the  exigencies  of  the 
case. 

“ M , an  inside  splint  covered  by  the  bandages.  Q,  the 
screw  by  which  extension  is  effected  in  the  ordinary 
way,  having  at  an  extremity  a swivel  and  hook,  tied  to 
a strip  of  wood  in  the  loop  of  adhesive  plaster  below  the 
foot.” 

In  the  apparatus  of  Sanborn,  of  Lowell,  Mass.  (Fig. 
401),  there  is  only  the  long  splint  used.  It  projects  as 
far  as  the  axilla,  where  it  supports  a crutch  (a)  moved  by 
a screw  (i);  the  lower  end  bears  a bar  of  iron  (c),  project- 
ing at  right  angles,  and  also  movable  by  a screw  ( d ).  In 
applying  this  splint,  two  long  strips  of  adhesive  plaster 
are  laid  upon  the  sides  of  the  leg,  extending  from  above 
the  knee  to  a point  two  or  three  inches  beyond  the  foot, 
and  secured  by  a roller.  The  ends  of  the  strip  form  a 
loop  to  catch  upon  the  cross-bar,  and  by  means  of  the 
screw  extension  can  be  regulated  at  will.  The  counter- 
extending band  is  put  on  in  the  usual  manner,  and  it  is  intended  by 
the  crutch  arrangement  that,  should  the  band  press  hurtfully  upon 
the  perineum,  it  may  be  temporarily  discontinued,  and  the  counter- 
extension  established  in  the  axilla. 


FRACTURE  OF  THE  FEMUR. 


465 


Practically,  this  cannot  be  continued  effectually  for  any  lengthy 
period,  for  it  is  instinctive  on  the  part  of  a patient,  in  order  to  avoid 
this  axillary  pressure,  and  especially  when  it  galls  at  all,  to  twist  the 
shoulders  to  the  opposite  side,  and  thus  destroy  the  counter-extension. 

Dr.  Neill,  of  Philadelphia,  has  employed  a contrivance,  by  means 
of  which  extension  and  counter  extension  may  be  sustained  at  the 
same  moment.  The  peculiarity  of  the  arrangement  consists  in  the 


Fig.  402. 


extending  and  counter-extending  bands  being  attached  to  a double 
cord  passing  along  the  outside  of  the  long  splint,  and  which  can  be 
shortened  at  pleasure  by  twisting  them  by  a short  peg  placed  between 
them  at  their  middle ; this  apparatus  is  not  unlike  one  described  by 
Du  Yerney. 

In  some  cases  of  fractured  thigh  it  will  be  found  necessary  to  dis- 
pense with  the  perineal  band  altogether,  and  then  the  surgeon  will 
find  in  the  adhesive  strips  an  invaluable  resource  in  making  counter- 
extension. The  peculiar  plan  now  to  be  described  was  introduced 
into  the  Pennsylvania  Hospital  by  Dr.  H.  L.  Hodge,  and  found  to  be 
effective  in  the  cases  in  which  it  was  tried.  I have  employed  it  in 
several  instances  with  gratifying  results ; it  enabled  me  to  keep  up 
efficient  counter-extension,  while  the  adhesive  strips  about  the  chest 
did  not  in  the  least  inconvenience  the  patient  further  than  the  appli- 
cation of  an  apparatus  requiring  continuous  dorsal  decubitus;  nor 
did  it  impede  respiration. 

In  Pigs.  403,  404,  it  will  be  seen  that  the  apparatus  consists  of 
an  ordinary  Desault’s  splint,  wide  enough  at  its  upper  end  to  permit 
the  iron  bar,  fastened  by  bolts  to  its  superior  edge,  to  pass  clear  of 
the  patient’s  shoulder.  The  bar  itself  is  bent  at  right  angles,  as  seen 
in  Pig.  404,  over  the  shoulder,  so  that  the  hook  at  its  extremity  may 
come  in  the  line  of  the  axis  of  the  injured  limb.  A broad  strip  is 
now  applied  upon  the  anterior  face  of  the  chest  from  the  groin  to  the 
shoulder,  where  a loop  is  left,  and  then  continued  down  the  back  to 
the  nates ; in  the  loop  a small  block  is  placed  to  keep  the  two  parts 
of  the  strip  separate,  and  also  from  wrinkling,  that  they  may  draw 
upon  the  body  in  parallel  lines.  The  block  is  connected  to  an  iron 
30 


466 


SPECIAL  FRACTURES. 


hook  by  a cord.  In  order  to  prevent  the  vertical  strip  slippino- 
upwards  by  the  tractile  force,  three  circular  strips  are  applied  to  the 
chest,  as  seen  in  Fig.  403. 


Fig.  403. 


Hodge’s  apparatus  for  counter-extension  in  fracture  of  the  thigh. 


Dr.  Gilbert,  of  Philadelphia,  has  recommended  the  substitution  of 
adhesive  strips  for  the  ordinary  band  used  in  making  counter-exten- 
sion. Fig.  405  shows  his  splint  with  the  adhesive  strap  attached. 


Fig.  405. 


Gilbert’s  mode  of  counter-extension. 


Fig.  406  illustrates  its  mode  of  application  in  a case  of  double  frac- 
ture of  both  thighs : 1,  is  the  anterior  counter-extending  strip,  two 
and  a half  inches  wide ; 2,  the  end  of  the  posterior  strip,  which  is 
brought  up  in  front;  3,  a pelvic  adhesive  strip,  three  inches  wide, 
which  serves  to  bind  the  two  former  strips  to  the  body;  4,  the  extend- 
ing strips,  which  form  a stirrup  under  the  foot  to  receive  the  strap 
of  the  tourniquet;  5,  the  tourniquet,  for  applying  the  extending 
power.  The  side-splints  are  applied  in  the  usual  mauuer  with  cush- 


FRACTURE  OF  THE  FEMUR.  467 

ions,  &c.,  as  seen  in  the  figure.  After  the  application  of  the  adhesive 
strap  a bandage  is  applied  from  the  ankle  upwards. 

Fig.  406. 


Gilbert’s  apparatus  applied. 

Dr.  Dugas,  of  Georgia,  applies  a weight  to  the  limb  for  the  purpose 

fof  making  extension,  and  directs  his  apparatus  to  be  applied  in  this 
manner : “ Suitable  compresses  having  been  placed  upon  the  thigh, 
apply  over  them  four  wooden  splints  a little  longer  than  the  femur 

Fig.  407. 


Dugas’  apparatus  applied. 


Fig.  408. 


(one  in  front,  one  in  the  rear,  and  one  on  either  side),  and  secure  them 
with  many-tailed  bandages  or  with  single  ties.  A two  or  three-pound 
weight  should  then  be  fixed  to  the  foot, 
and  hung  over  the  footboard  of  the  bed, 
as  indicated  in  Fig.  407,  so  as  to  keep 
up  extension,  while  the  resistance  of 
the  patient’s  body  will  effect  counter- 
extension. A splint  four  inches  wide, 
and  extending  from  the  side  of  the  thorax 
to  a little  below  the  foot,  will  now  serve 
to  keep  the  limb  straight,  and  to  main- 
tain the  foot  in  a proper  position.  This 
! splint  should  be  secured  by  separate  ties 
passed  around  the  abdomen,  pelvis,  thigh,  leg,  and  foot.  Finally,  an 
arch  of  crossed  hoops  should  protect  the  toes  from  the  bedclothes. 

Fig.  408  shows  the  manner  in  which  Dr.  Dugas  attaches  the  extend- 
ing band  to  the  ankle. 

Dr.  Gurdon  Buck,  of  New  York,  makes  extension  witb  adhesive 


Dugas’  mode  of  attaching  the  extending 
band. 


468 


SPECIAL  FRACTURES. 


strips,  connected  with  a weight  varying  from  five  to  twenty  pound?. 
The  counter-extending  band  is  composed  of  an  India-rubber  tube,  an 
inch  in  diameter  and  two  feet  long,  stuffed  with  bran  or  cotton  lamp- 
wick,  and  covered  with  Canton  flannel.  As  seen  in  Fig.  409,  he  dis- 

Fig.  409. 


Dr  Buck’s  apparatus. 


cards  the  long  splint,  the  limb  being  simply  enveloped  in  a roller 
bandage,  and  short  splints  applied  to  the  leg. 

The  methods  of  making  extension  with  the  gaiter  and  cravat,  for- 
merly used  (Figs.  410,  411),  have,  of  late  years,  been  happily  dis- 


Fig.  410.  Fig.  411. 


Mode  of  making  extension  with  the  gaiter.  Mode  of  making  extension  with  the  cravat. 

carded;  adhesive  strips  are  now  employed  for  this  purpose,  and  tbe 
advantages  over  the  former  are  incontestable,  among  the  chief  of 
which  may  be  mentioned  the  simplicity  of  the  plan,  and  the  requisite 
amount  of  force  being  attainable  without  inflicting  injurious  pressure 
upon  the  insteps  and  margins  of  the  foot. 

Two  broad  strips  should  be  cut  in  the  length  of  the  plaster,  and 
well  stretched,  so  that  they  may  not  yield  when  applied  to  the  leg. 
and  the  extending  force  is  exerted ; they  must  reach  well  up  the  limb 
to  get  a good  purchase,  and  have  circular  strips  of  the  same  material 
and  a roller  bandage  laid  over  the  whole,  as  seen  in  Fig.  412. 

M.  Gfariel,  who  has  been  instrumental  in  applying  India-rubber  to 
so  many  useful  surgical  purposes,  advises,  in  treatment  of  fractures, 
the  use  of  elastic  extending  and  counter-extending  lacs.  His  appa- 
ratus, as  described  by  Jamain,  is  composed,  1st,  of  a sort  of  stirrup  in 
the  form  of  a circular  sac  embracing  the  ankle,  and  shaped  in  such  a 
manner  that  when  it  is  inflated,  it  is  converted  into  a cushion  exactly 


FRACTURE  OF  THE  FEMUR. 


469 


moulded  to  the  limb,  in  contact  with  the  latter  at  every  part  of  the 
surface,  and  consequently  exercising  a perfectly  uniform  pressure. 

Fig.  412. 


Fig.  413. 


This  can  be  rendered  still  more  gentle  by  the  application,  around 
the  extremity  of  the  limb  that  supports  the  extending  stirrup,  of  a 
roller  which  possesses  the  double  advantage  of  preventing  the  swell- 
ing of  the  foot,  and  the  immediate  compression  of  the  tissues  by 
the  apparatus.  The  traction  is  effected  by  means  of  two  exten- 
sions of  the  stirrup,  strong  cords,  which,  although  flexible,  and  espe- 
cially eminently  retractile,  stretch  sufficiently  without  losing  their 
capacity  for  contraction,  and  thus  assuring  a continuous  and  perfectly 
exact  traction;  2d,  of  a counter-extending  lac,  a tube  of  India-rubber 
about  thirty-nine  inches  long,  presenting  at  its  middle  point  an  en- 
largement destined  to  exercise  pressure 
.upon  a wider  surface.  This  enlarged 
portion  ought  to  be  placed  upon  the 
groin  of  the  side  of  the  fracture,  and  ex- 
tend just  beyond  the  perineum.  The  ex- 
tending cords  are  attached  to  the  lower 
part  of  the  bedstead. 

Mr.  Erichsen  says  that  the  starched 
bandage  may  be  employed  in  most  cases 
of  fracture  of  the  shaft  of  the  femur,  and 
that  with  the  apparatus  seen  in  Fig.  413 
he  has  treated  many  such  cases,  both  in 
adults  and  children,  without  confinement 
to  bed  for  more  than  three  or  four  days, 
and  without  the  slightest  shortening  or 
deformity  being  left.  His  manner  of  pro- 
ceeding is  described  by  him  thus : “A  dry 
roller  should  be  applied  to  the  whole  of 
the  limb  evenly  and  neatly,  which  must 
then  be  covered  with  a thick  layer  of 
wadding;  a long  piece  of  strong  paste- 
board, about  four  inches  wide,  soaked  in 
starch,  must  next  be  applied  to  the  pos- 
terior part  of  the  limb,  from  the  nates  to 
the  heel.  If  the  patient  is  very  muscular, 
and  the  thigh  large,  this  must  be  straight- 
ened, especially  at  its  upper  part,  by 
having  slips  of  bandage  pasted  upon  it.  Two  narrower  strips  of 
pasteboard  are  now  placed  along  either  side  of  the  limb  from  the  hip 


Mode  of  applying  the  starched  bandage 
in  fractured  thigh. 


470 


SPECIAL  FRACTURES. 


to  the  ankle,  and  another  shorter  piece  on  the  forepart  of  the  thigh. 
A double  layer  of  starched  bandage  should  now  be  applied  over  the 
whole,  with  a strong  and  well-starched  spica.  It  should  be  cut  up  and 
trimmed  on  the  second  or  third  day,  and  then  reapplied  in  the  usual 
way.” 

This  method  of  treatment  will  require  the  greatest  watchfulness  by 
the  surgeon,  to  see  that  no  danger  comes  of  constricting  the  limb, 
either  from  the  subsequent  swelling,  or  from  too  tight  application  of 
the  roller  bandage.  Apparatus  of  the  same  description  have  been 
recommended  by  Seutin,  Larrey,  and  Velpeau,  as  already  described. 

In  whatever  way  a fracture  of  the  shaft  of  the  femur  is  managed,  it 
demands  the  daily  surveillance  of  the  surgeon;  any  injurious  pressure 
of  the  splints  upon  the  bony  prominences  of  the  limb  must  be  cor- 
rected by  shifting  the  cushions,  introducing  compresses  between  the 
limb  and  the  splints,  and  the  frequent  application  of  stimulating 
washes,  of  which  one  of  the  best  is  the  camphorated  tincture  of  soap. 

The  patient  must  be  kept  in  the  apparatus  seven  or  eight  weeks, 
though  in  some  cases  the  removal  may  be  made  safely  at  an  earlier 
period ; or,  on  the  other  hand,  require  it  to  be  delayed  beyond  the 
time  stated  above. 

At  first  the  extension  should  be  gradual,  and,  in  proportion  to  the 
capability  of  the  patient  to  bear  it,  it  must  be  increased  to  the  fullest 
extent  required,  which  perhaps  may  be  accomplished  in  six  or  eight 
days.  When  the  case  has  progressed  favorably,  the  extending  bands 
may  be  removed  in  four  or  five  weeks,  and  the  long  splint,  with  a 
footboard  attached,  only  retained,  which  will  hold  the  limb  securely 
until  the  consolidation  becomes  firm  enough  to  support  the  weight  of 
the  body.  At  this  time— in  about  eight  weeks — the  patient  will  be 
permitted  to  rise  and  go  about  upon  crutches  for  two  or  three  months, 
when  they  may  be  laid  aside. 

With  a careful  patient,  I have  sometimes  removed  the  straight 
splints  in  two  weeks  and  applied  the  starched  bandage,  and  permitted 
him  to  go  about. 

3.  Fracture  of  the  Condyles  of  the  Femur. — The  condyles  may  be 
separated  from  the  shaft  of  the  femur  at  their  base,  or,  at  the  same 
time  that  they  are  separated  thus,  another  line  of  fracture  passes 
between  them.  Other  instances  are  recorded  where  one  or  the  other 
condyle  alone  is  broken  from  the  shaft.  a 

Causes. — -This  injury  is  produced  by  the  application  of  great  vio- 
lence, falls  or  blows  upon  the  knee,  the  passage  of  the  wheel  of  a cart 
over  the  part,  &c. 

The  displacement,  if  the  fracture  is  oblique,  will  always  be  of  the 
lower  fragment  backwards ; on  the  other  hand,  this  may  be  very  little 
in  transverse  fracture.  In  separation  of  the  condyles,  lateral  displace- 
ment occurs. 

Symptoms. — Preternatural  mobility  at  the  seat  of  fracture : the  al- 
ternate flexion  and  extension  of  the  leg  will  produce  crepitus;  short- 
ening. When  the  condyles  are  separated  from  each  other,  they  may 
be  seized  upon  each  side  with  the  fingers,  and  moved  in  opposite 
directions,  the  motion  producing  crepitus ; shortening  will  be  mani- 


FRACTURE  OF  THE  PATELLA. 


471 


fest;  the  knee-joint  appears  to  have  widened  out,  and  the  patella 
depressed  between  the  condyles. 

Prognosis. — These  fractures  will  generally  be  attended  with  violent 
inflammation  in  or  about  the  knee-joint,  rendering  the  case  always 
serious.  Anchylosis  will  perhaps  be  one  of  the  most  favorable  results 
that  can  be  obtained.  More  or  less  shortening  must  be  expected. 

Treatment. — In  fracture  of  either  condyle,  the  limb  may  be  placed 
in  a straight  position,  and  pasteboard  or  gutta-percha  splints  applied 
and  secured  with  a roller. 

When  the  condyles  are  separated  from  the  shaft,  or  from  the  shaft 
and  each  other,  moderate  extension  will  be  required  upon  the  limb, 
placed  either  in  the  flexed  or  straight  position,  some  surgeons  prefer- 
ring the  former,  and  others  the  latter;  whichever  plan  is  selected,  the 
apparatus  previously  described  will  supply  the  means  to  carry  it  into 
effect. 

Fracture  of  the  Patella. — Fracture  of  the  patella  is  not  uncom- 
mon ; the  bone  is  generally  broken  in  a transverse  direction  (Fig.  414), 
though  the  line  of  fracture  maybe  vertical,  or  again  run  in  two  or  three 
directions  so  that  the  patella  will  be  divided  into  three  or  more  pieces. 
(Fig.  415.) 

Causes. — In  the  first  instance,  the  cause  of  the  fracture  is  most  com- 
monly violent  muscular  effort,  as  when  a person  falling  backwards 
endeavors  to  save  himself  by  a great  effort,  or  in  jumping  or  kicking; 
the  transverse  fracture  also  results  from  blows.  Longitudinal  and 
comminuted  fracture  is,  in  a majority  of  instances,  the  result  of  some 
direct  injury,  and  is  attended  with  much  swelling,  pain,  and  inflam- 
mation about  the  joint. 


Fig.  414.  Fig.  415. 


Fracture  of  the  patella. 


The  displacement  observed  is  a separation  of  the  upper  from  the 
lower  fragment,  which  retains  its  position  in  consequence  of  its  con- 
nection with  the  tibia  by  the  ligament  of  the  patella.  The  direction 
of  the  displacement  is  upwards,  and  varies  in  amount  from  a few  lines 
to  four  inches  or  more,  according  to  the  extent  to  which  the  aponeu- 
rosis connected  with  it  is  lacerated. 

Symptoms. — This  injury  is  of  easy  recognition.  The  upper  fragment 
can  be  felt  to  be  drawn  up,  leaving  a depression  between  it  and  the 
lower  one  in  which  the  finger  may  be  placed.  If  the  fragments  can  be 
brought  into  apposition,  crepitus  may  be  developed  by  rubbing  them 
together.  The  patient,  at  the  time  of  the  injury,  will  feel  a crack,  per- 
haps in  the  knee,  and  find  himself  unable  to  stand  upon  the  limb,  or 
to  extend  the  leg. 


472 


SPECIAL  FRACTURES. 


Prognosis. — Union  in  fractured  patella  occurs  almost  always  by  liga- 
ment, in  rare  instances  that  by  bone  has  been  observed.  The  recovery 
will  commonly  take  place  without  any  further  difficulty  than  perhaps 
a little  stiffness  of  the  knee,  which  gradually  disappears.  It  has  been 
noticed  that  when  the  separation  between  the  fragments  is  consider- 
able, and  connected  by  a long  ligamentous  band,  the  limb  in  the  exer- 
cise of  its  functions  will  be  impaired  a long  time,  but  will  ultimately 
be  restored  to  the  full  possession  of  its  motions. 

Treatment. — The  treatment  of  fractured 'patella  consists  in  subduing 
local  inflammation,  restoring  the  fragments  in  apposition,  and  main- 
taining them  in  this  position  by  appropriate  mechanical  means,  until 
the  union  has  been  effected. 

The  first  indication  is  answered  by  the  use  of  leeches  and  cold  ap- 
plications. The  third  indication  will  be  fulfilled  by  the  employment 
of  certain  apparatus,  of  which  there  are  a large  number,  recommended 
by  various  surgeons. 

Mr.  Liston  recommended  a very  suitable  contrivance.  The  foot 
and  leg,  to  a point  just  below  the  knee,  are  enveloped  in  a roller  band- 
age to  prevent  swelling ; the  limb  placed  upon  a padded  splint,  hol- 
lowed at  both  ends,  reaching  from  the  tuberosity  of  the  ischium  to  a 
point  a little  below  the  middle  of  the  calf;  after  bringing  the  upper 
fragment  down  to  its  normal  position,  a roller  is  passed  around  the 
limb  and  the  splint  from  the  toes  to  the  groin,  making  several  crosses 
at  the  knee.  Mr.  Amesbury  employed  soft  padded  leather  bands,  long 
enough  to  go  half  around  the  limb,  and  having  straps  and  buckles 
attached  to  their  ends,  by  means  of  which  they  were  confined  to  the 
limb,  one  upon  the  lower  part  of  the  thigh,  and  the  other  upon  the 
leg  below  the  knee.  To  the  lower  margin  of  the  upper  band  a buckle 
is  attached  upon  each  side  of  the  patella ; corresponding  to  these 
buckles  two  straps  were  fastened  to  the  upper  margin  of  the  lower 
band.  By  approximating  the  borders  of  the  bands,  the  upper  frag- 
ment is  drawn  down  towards  the  knee. 

Instead  of  the  wooden  splint  of  Liston,  Dr.  Gross,  of  Philadelphia, 
recommends  the  employment  of  a padded  tin  case,  extending  from 
the  middle  of  the  thigh  to  a corresponding  point  of  the  calf.  A rol- 
ler is  to  be  applied  upon  the  leg  from  the  toes  upwards,  and  another 
upon  the  thigh  from  the  groin  downwards;  the  displaced  fragment  is 
to  be  brought  down,  and  confined  by  numerous  adhesive  strips,  car- 
ried around  the  bone  above  and  below  the  joint,  and  connected  after- 
wards by  vertical  and  transverse  pieces.  A long,  thick,  and  very 
narrow  compress  should  extend  around  the  upper  border  of  the 
patella,  and  confined  by  the  two  rollers  passed  around  the  joint  in  the 
form  of  the  figure  of  8. 

Dr.  Sanborn,  of  Lowell,  Mass.,  suggests  a way  of  treating  a fractured 
patella  by  a single  adhesive  strip  twisted  above  the  knee.  He  directs 
“ a strip  of  ordinary  adhesive  plaster,  four  feet  long  and  two  and  a half 
inches  wide,  to  be  applied  to  the  limb  from  the  upper  portion  of  the 
thigh  to  the  middle  of  the  leg,  leaving  at  the  knee  a free  loop  (Fig.  417). 
A roller  bandage  is  then  applied  above  and  below  the  knee,  for  the  pur- 
pose of  securing  the  plaster,  and  controlling  the  circulation  and  mus- 


FRACTURE  OF  THE  PATELLA. 


473 


cular  contraction.  A small  stick  six  or  eight  inches  in  length  then 
being  put  through  the  loop  over  the  knee,  the  plaster  is  to  be  twisted 


Fig.  416. 


until  the  patella  is  brought  near  down  to  its  proper  situation.  Before 
applying  the  twist  a hard  compress  is  to  be  placed  above  the  patella 


Fig.  417. 


in  such  a manner  as  to  bring  the  force  to  bear  directly  upon  the 
bone.”  (Fig.  416.) 

One  method  pursued  by  Sir  A.  Cooper  is  seen  in  Fig.  418.  He 
recommended  that  the  limb  should  be  lightly  bandaged  to  a splint 


Fig.  418. 


extending  from  the  ischium  to  the  heel,  leaving  the  knee  uncovered ; 
he  thigh  is  then  to  be  flexed  upon  the  trunk,  and  the  limb  reposed 
lpon  an  inclined  plane,  while  the  antiphlogistic  remedies  are  to  be 
;iad  recourse  to  until  the  inflammatory  swelling  shall  have  abated. 
Then  a roller  is  to  be  applied  to  the  leg,  from  the  toes  to  the  knee,  to 
orevent  engorgement;  upon  each  side  of  the  limb  a strong  tape  is 
aid  and  confined  above  and  below  the  knee  by  a roller  bandage; 
heir  extremities  are  now  to  be  drawn  together  and  tied.  Sometimes 
h band  is  put  in  front  of  the  knee,  and  arranged  in  the  same  manner. 


474 


SPECIAL  FRACTURES. 

/ 

The  same  distinguished  surgeon  describes  another  apparatus  (Fig. 
419)  for  the  same  purpose.  A leather  belt  surrounds  the  lower  part 


Fig.  419. 


of  the  thigh  above  the  upper  fragment.  To  the  side  of  this  a long 
strap  is  attached  which  is  intended  to  pass  beneath  the  sole  of  the 
foot,  up  the  opposite  side  of  the  limb,  to  be  buckled  to  the  thigh-belt; 
tapes  secure  the  strap  from  slipping  from  the  leg.  As  in  the  other 
contrivance,  a roller  bandage  is  to  be  previously  applied  to  the  leg. 

Mr.  John  Wood,  of  London,  contrived  the  apparatus  seen  in  Fig. 
420.  It  consists  of  a long  splint  extending  from  the  tuberosity  of  the 


Fig.  420. 


ischium  to  within  a short  distance  of  the  heel;  from  the  end  of ‘this 
two  short  lateral  curved  iron  bars  extend,  supporting  a footboard,  and 
bent  at  right  angles  to  be  fixed  to  a block  which  raises  the  splint  from 
the  bed.  To  each  side  of  the  splint  two  hooks  are  fastened,  one  above 
the  knee  and  the  other  below. 

In  applying  the  apparatus  the  splint  is  well  padded  and  the  limb 
laid  upon  it;  a roller  bandage  is  now  applied  from  the  toes  upwards, 
arriving  at  the  knee,  after  the  fragment  has  been  drawn  down,  the 
roller  is  made  to  form  a figure  8 about  it,  the  turns  of  which  are  pre- 
vented from  slipping  by  the  hooks. 

Prof.  Hamilton  has  adopted  a much  better  form  of  splint  than  the 
preceding,  and  one  I have  used  in  three  cases  with  decided  success. 
It  is  seen  in  Fig.  421,  and  he  describes  it  in  the  following  language: 
“The  dressing  consists  of  a single  inclined  plane,  of  sufficient  length 
to  support  the  thigh  and  leg,  and  about  six  inches  wider  than  the 
limb  at  the  knee.  This  plane  rises  from  a horizontal  floor  of  the 
same  length  and  breadth,  and  is  supported  at  its  distal  end  by  an 


FRACTURE  OF  THE  PATELLA. 


475 


upright  piece  of  board,  which  serves  both  to  lift  the  plane  and  to 
support  and  steady  the  foot.  The  distal  end  of  the  inclined  plane 
may  be  elevated  from  six  to  eighteen  inches,  according  to  the  length 
of  the  limb  and  other  circumstances.  Upon  either  side,  about  four 


Fig.  421. 


inches  below  the  knee,  is  cut  a deep  notch.  The  foot-piece  stands  at 
right  angles  with  the  inclined  plane,  and  not  at  right  angles  with  the 

I horizontal  floor ; it  may  be  perforated  with  holes  for  the  passage  of 
tapes  or  bandages  to  secure  the  foot. 

“ Having  covered  the  apparatus  with  a thick  and  soft  cushion  care- 
fully adapted  to  all  the  irregularities  of  the  thigh  and  leg,  especial 
care  being  taken  to  fill  completely  the  space  under  the  knee,  the  whole 
limb  is  now  laid  upon  it,  and  the  foot  secured  gently  to  the  footboard, 
between  which  and  the  foot  another  cushion  is  placed. 

“ The  body  of  the  patient  should  also  be  flexed  upon  the  thigh,  so 
as  the  more  effectually  to  relax  the  quadriceps  femoris  muscle. 

“ A compress  made  of  folded  cotton  cloth,  wide  enough  to  cover 
the  whole  breadth  of  the  knee,  and  long  enough  to  extend  from  a 
point  four  inches  above  the  patella  to  the  tuberosity  of  the  tibia, 
and  one-quarter  of  an  inch  thick,  is  now  placed  on  the  front  of,  and 
above  the  knee.  While  an  assistant  presses  down  the  upper  fragment 
of  the  patella  the  surgeon  proceeds  to  secure  it  in  place  with  bands  of 
adhesive  plaster.  Each  band  should  be  two  or  two  and  a half  inches 
wide,  and  sufficiently  long  to  inclose  the  limb  and  splint  obliquely. 
The  centre  of  the  first  band  is  laid  upon  the  compress  partly  above 
and  partly  upon  the  upper  fragment,  and  its  extremities  are  brought 
down  so  as  to  pass  through  the  two  notches  on  the  side  of  the  splint 
and  close  upon  each  other  underneath.  The  second  band,  imbricating 
the  first,  descends  a little  lower  upon  the  patella,  and  is  secured  below 
in  the  same  manner.  The  third,  and  so  on  successively  until  the 
whole  extent  of  the  compress  and  knee  is  covered,  is  carried  more 
nearly  at  right  angles  around  the  leg  and  splint ; the  last  bands  pass- 
ing obliquely  from  below  the  ligamentum  patellae  upwards  and  back- 
wards. The  dressing  is  now  completed  by  passing  a cotton  roller 
around  the  whole  length  of  the  limb  and  splint,  commencing  at  the 


476 


SPECIAL  FRACT'URES. 


toes  and  ending  at  the  groin.  This  is  applied  lightly,  as  its  object 
is  only  to  support  and  steady  the  limb  upon  the  splint.”  The  supe- 
riority of  this  apparatus  is  that  it  does  not  obstruct  the  circulation  by 
constricting  the  limb,  as  there  is  ample  space  between  the  bandage 
and  sides  of  the  limb. 

A rather  complicated  apparatus  was  employed  by  Mr.  Lonsdale, 
but  it  has  the  recommendation  of  being  efficient  (Fig.  422). 


Fig.  422. 


It  consists  of  a well-padded  splint  extending  along  the  posterior 
surface  of  the  limb,  and  supporting  at  its  further  end  a footboard 
which  may  be  moved  up  or  down  to  accommodate  the  splint  to  limbs 
of  different  length.  From  the  bottom  of  the  splint  in  the  neighbor- 
hood of  the  knee-joint  two  vertical  metallic  bars,  A B,  project,  each 
bearing  an  iron  stem,  Gf  G,  bent  at  right  angles  moving  upon  it,  and 
capable  of  being  fixed  at  any  point  by  the  thumb-screw,  C D — the 
two  portions  of  the  stems  in  the  axis  of  the  limb  support  sliding  pins 
having  attached  to  their  inferior  extremities  padded  metal  plates  of 
a semilunar  shape,  intended  to  press  upon  the  fragments  above  and 
below.  In  employing  the  apparatus  the  limb  is  laid  upon  the  splint 
and  secured  to  it  by  a roller  bandage,  and  after  the  upper  fragment 
is  drawn  down  the  semilunar  pads  are  placed  against  the  upper  and 
lower  borders  of  the  patella  and  fixed  by  the  screws.  To  relax  the 
quadriceps  femoris,  the  lower  end  of  the  splint  is  raised  from  the 
mattress  upon  a little  frame. 

Surgeon  P.  Lansdale,  U.  S.  Navy,  has  invented  a very  ingenious 
and  efficient  splint  seen  in  Fig.  423.  It  holds  the  fragments  in  exact 


Fig.  423. 


apposition,  and  does  not  constrict  the  limb.  It  is  constructed  with  a 
posterior  padded  splint  upon  which  the  limb  is  secured  with  a roller 


FRACTURE  OF  THE  PATELLA. 


477 


bandage.  From  a point  a short  distance  above  the  knee  an  iron  loop 
or  arc  spans  the  limb  obliquely,  and,  when  in  position,  its  top  is  below 
the  patella ; a similar  arc  is  fastened  to  the  splint  at  a corresponding 
point  below  the  knee,  and  its  top,  when  in  position,  is  above  the  knee. 
Bach  of  these  arcs  bears  a screw  at  its  centre  armed  with  a semilunar 
pad.  In  the  application  of  this  apparatus  after  the  limb  is  secured  to 
the  splint,  it  is  simply  necessary  to  bring  the  upper  fragment  down, 
and  with  the  upper  screw  clamp  the  pad  against  it ; in  like  manner 
clamp  the  inferior  fragment  with  the  lower  pad.  This  holds  the 
pieces  of  the  patella  firmly  together  so  that  it  is  impossible  for  them 
to  escape. 

M.  Malgaigne,  struck  by  the  general  inefficiency  of  the  apparatus 
employed  in  France  for  fractured  patella,  devised  the  instrument  seen 
in  Fig.  424.  It  consists  of  two  pairs  of  sharp- 
pointed  hooks  movable  towards  each  other  by  a 
screw,  and  intended  to  take  their  point  cl'appui  di- 
rectly upon  the  bony  fragments  above  and  below. 

In  applying  the  instrument  the  hooks  are  thrust 
through  the  skin  down  to  the  margins  of  the  frag- 
ments, and  by  the  action  of  the  screw  these  are 
brought  into  close  contact  and  retained  in  this  posi- 
tion six  weeks,  or  until  their  union  is  accomplished. 

I have  employed  Malgaigne’s  apparatus  in  one 
case  with  decided  success ; and  there  were  no  trou- 
blesome symptoms  presented  during  the  treatment, 
which,  I must  confess,  at  first,  I feared  would  occur 
from  the  proximity  of  the  hooks  to  the  knee-joint. 

A very  simple  but  efficient  application  of  the 
Spanish  windlass  or  handkerchief  and  stick  arrange- 
ment to  the  back  splint,  in  the  treatment  of  trans- 
verse fracture  of  the  patella,  is  recommended  by 
Dr.  Edward  Hartshorne,  who  has  employed  it  with 
great  advantage  in  hospital  and  private  practice, 
having  used  it  first  in  the  Pennsylvania  Hospital  in 
1862. 

The  splint,  which  should,  of  course,  be  carefully  padded,  is  not 
peculiar,  except  that,  in  accordance  with  an  old  rule,  it  is  always 
hroad  enough  above  and  below  the  knee  to  prevent  the  bandages 
from  constricting  or  pressing  on  the  sides  of  the  limb  in  their  passage 
backwards  from  the  margins  of  the  patella ; and  is  also  furnished  on 
its  sides,  at  proper  distances,  above  and  below  the  knee,  with  the 
notches  or  projecting  cleets,  pins,  or  hooks  which  are  required  to  hold 
the  bandage.  This  bandage  may  be  the  common  roller  or  adhesive 
! strips,  or  even  a band  or  ring  of  elastic  webbing ; but  inelastic  webbing, 
or  linen,  or  cotton  drilling  from  one  and  a half  to  two  inches  wide  in 
the  central  portion  and  narrower  at  its  ends,  answers  better,  especially 
if  the  surfaces  which  we  apply  to  the  integument  above  and  below 
the  fragments  are  thinly  spread  with  old  adhesive  plaster.  The  lower 
fragment  is  fixed  in  the  usual  way,  and  retained  in  position  by  simply 
applying  one  of  the  bandages  by  its  wider  central  portion  in  front  o-f 


478 


SPECIAL  FRACTURES. 


the  knee-joint  directly  to  the  lower  margin  of  this  fragment,  then 
passing  the  two  narrower  ends  obliquely  upwards  and  backwards  and 
drawing  them  firmly  together  over  the  upper  cleets,  pins,  or  notches, 
and  behind  the  splints,  there  to  be  fastened  in  any  manner  most  con- 
venient. 

The  bandage  or  band  for  the  upper  fragment  requires  more  careful 
application  and  adjustment,  as  it  is  to  exert  all  the  pressure  and  trac- 
tion force  necessary  to  bring  the  fragment  down,  and  retain  it  in 
apposition  with  the  fixed  lower  fragment.  Having  been  applied  to 
the  integument  just  above  and  slightly  over  the  margin  of  this  upper 
fragment,  it  is  then  drawn  firmly  downwards  and  forwards  over  the 
notches  or  cleets  in  such  an  oblique  direction  as  may  be  found  the 
best  for  efficient  traction  in  each  particular  case.  The  two  ends  are 
firmly  fastened  together,  and  a small  stick  (or,  what  is  better,  the  little 
wooden  fork  called  a clothes-pin),  passed  between  the  band  and  the 
splint,  is  turned  or  twisted  on  its  long  axis  in  such  a way  as  to  draw 
upon  the  bandage  to  any  proper  extent.  This  arrangement  allows 
the  whole  knee,  especially  the  injured  parts  and  the  compressing 
bandages,  to  remain  uncovered,  at  the  same  time  that  it  gives  entire 
control  of  the  joint  and  of  the  separated  fragments,  as  well  as  of  the 
dressing  itself.  Compresses  of  lint  or  other  material  may  be  employ- 
ed, but  they  are  not  often  needed,  particularly  when  adhesive  plaster 
is  spread  upon  the  central  portion  of  the  bandage.  Tilting  of  the 
fragments  may  be  prevented  by  a transverse  bandage,  or  by  a narrow, 
well-padded  transverse  splint  pressing  upon  the  line  of  fraclure.  The 
ease  and  certainty  with  which  the  traction  may  be  lessened  or  increased 
by  the  slightest  turn  of  the  twisting-stick  or  pin,  at  the  same  time 
that  this  pin  may  be  fastened  beyond  the  reach  or  control  of  the 
patient,  renders  this  contrivance  remarkably  effective ; while  the  sim- 
plicity of  materials  and  arrangement  bring  it  readily  within  the  reach 
of  every  one.  The  same  care  in  all  essentials,  and  especially  in  adapt- 
ing the  splint  and  bandage,  as  to  length  and  width  of  the  former,  and 
the  distance  apart  of  the  cleets  or  notches,  and  the  width  and  ob- 
liquity of  the  latter,  must  be  observed  in  the  use  of  this  mode  of 
dressing,  as  in  other  more  complex  or  different  arrangements.  Dr. 
Hartshorne’s  method  has  been  tried  sufficiently  often  under  his  own 
observation,  to  satisfy  him  that  it  works  well  in  every  respect; 
having  been  found  very  comfortable  to  patients,  even  after  considera- 
ble inflammation  of  the  soft  parts,  and  under  long-continued,  close 
approximation  of  the  fragments ; requiring  less  attention  than  usual 
in  maintaining  the  adjustment;  and  being  followed,  in  several  in- 
stances, by  inappreciable  separation,  if  not  actual  consolidation. 

Various  contrivances  for  graduating  traction  behind  the  splint,  or 
on  its  sides — such  as  wedges,  screws,  buttons,  elastic  rings  or  straps, 
as  well  as  neater  forms  of  wooden  or  metallic,  and  guttered  splints  in 
the  usual  shapes — might  be  suggested;  but  they  are  all  objected  to 
by  Dr.  Hartshorne,  on  account  of  their  complexity  and  costliness,  from 
which  his  bandage  and  stick  are  free. 

To  meet  the  desire  for  a more  convenient  and  comfortable  dressing, 
especially  during  convalescence,  and  in  case  of  injurious  separation 


FRACTURE  OF  THE  PATELLA. 


479 


of  the  fragments  from  defective  treatment,  he  has,  with  the  aid  of 
Mr.  Kolbe,  devised  a light  tin  case,  fitting  to  the  limb  behind,  lacing 
in  front  of  the  thigh  and  the  leg,  and  being  provided  with  straps 
(elastic  or  not,  according  to  circumstances),  which  are  to  be  applied, 
as  usual,  across  the  joint,  above  and  below  the  patella,  and  drawn 
obliquely  to  be  fastened  and  tightened  by  means  of  a wedge  or  screw. 
Such  an  apparatus,  properly  made,  would  be  found  very  convenient 
to  those  in  whom  the  treatment  is  sufficiently  advanced  to  admit  of 
moving  about,  as  well  as  to  all  patients  who  are  willing  to  indulge  in 
the  expense  of  an  unnecessarily  luxurious  kind  of  splint. 

Dr.  Hartshorne  has  applied  the  same  dressing  in  a still  simpler 
form,  with  entire  success,  to  the  treatment  of  fractured  olecranon.  In 
this  fracture,  as  in  the  other,  the  splint  must  be  wide  enough  below 
the  elbow-joint  to  avoid  constriction,  and  but  one  bandage  and  one  set 
of  notches  or  projecting  cleets  are  needed.  The  application  of  the 
bandage,  which  is  evident  enough,  has  been  found  to  work  admirably. 
The  Spanish  windlass  may  be  usefully  resorted  to,  as  it  doubtless  has 
been,  in  the  production  of  compressing  force  for  different  purposes  in 
other  parts  of  the  body.  Dr.  Hartshorne  has  found  it  an  excellent 
substitute  for  Malgaigne’s  screw-pin  and  collar  in  managing  the  trou- 
blesome displacement  of  the  lower  fragment  in  oblique  fracture  of  the 
tibia.  With  a sufficiently  wide  and  well-padded  splint,  and  a judi- 
cious employment  of  compresses,  he  has  been  able  to  effect  very 
nearly,  if  not  quite  as  much  by  means  of  the  bandage  and  stick,  as 
can  be  done  either  with  the  saddle-shaped  pads,  with  which  Dr.  Prince 
has  improved  upon  the  pointed  screw  of  Malgaigne,  or  with  the  latter 
more  formidable  instrument. 

The  foot  ought  to  be  supported,  at  least  in  the  early  stages  of  treat- 
ment of  fractured  patella.  It  may  be  effected  either  with  a long 
splint  furnished  with  a footboard,  with  a fracture-box  or  trough,  with 
a footboard  attached  to  the  bedstead,  or  with  plenty  of  pillows.  This 
support  is  not  indispensable,  but  it  is  advantageous  and  comfortable. 

In  carrying  out  the  mechanical  treatment  of  fractured  patella, 
Dr.  Hartshorne  has  secured,  by  his  apparatus,  several  important  ad- 
vantages. He  avoids  circular  and  lateral  constriction,  keeps  the  parts 
in  view  uncovered  and  cool,  with  room  for  lotions,  if  desirable,  and 
produces  and  maintains  ample  traction  in  a sufficiently  effective  direc- 
tion, taking  care  to  prevent  tilting,  and  to  cause  a close  approxima- 
tion of  the  fractured  surfaces,  all  with  the  simplest  possible  means  and 
materials.  He  does  not  elevate  the  extremity,  nor  very  strongly  ex- 
tend the  leg.  Both  of  these  positions,  elevation  and  extension,  are 
uncomfortable,  fatiguing,  and  unnecessary. 

In  fracture  of  the  patella  it  will  be  necessary  to  continue  the  splint 
seven  or  eight  weeks,  at  the  lapse  of  which  time  daily  passive  motion 
must  be  inflicted  upon  the  knee-joint.  The  patient  may  be  permitted 
to  get  up  and  go  about  on  crutches,  but,  in  order  to  avoid  stretching 
of  the  ligamentous  band,  the  limb  should  be  kept  extended  by  a 
straight  splint  applied  to  its  posterior  surface  for  two  or  three  weeks 
more. 


480 


SPECIAL  FRACTURES. 


Fracture  of  the  Tibia  and  Fibula. — Fracture  of  the  tibia  and 
fibula  constitutes  more  than  half  the  cases  of  this  sort  of  injury  affect- 
ing the  bones  of  the  leg.  It  is  here  that  we  meet  with  a large  propor- 
tion of  compound  and  comminuted  fractures.  Both  bones  may  be 
broken  at  the  same  or  different  heights  ; in  the  first  instance  (Fig.  425) 


the  fracture  will  be  found  usually  located  at  the  junction  of  the  upper 
witb  the  middle  third,  and  in  the  latter  the  tibia  will  usually  give 
way  in  the  lower  third  and  the  fibula  in  its  upper,  as  seen  in  Fig.  426. 

The  line  of  fracture  is,  in  a majority  of  cases,  oblique,  yet  it  is 
sometimes  transverse,  and  will  then  occur  usually  at  some  point  in 
the  upper  third  of  the  tibia ; the  fracture  of  the  fibula  is  almost  always 
oblique. 

Causes . — The  commonest  cause  of  fracture  of  the  leg  is  the  appli- 
cation of  direct  violence,  as  the  fall  of  a heavy  weight  upon  the  limb, 
the  rolling  of  the  wheel  of  some  sort  of  vehicle  over  it,  heavy  blows. 
&c.  Again,  a person’s  weight  coming  upon  the  soles  of  the  feet  in 
jumping  from  a height  will  also  produce  the  fracture.  It  is  in  those 
cases  from  direct  injury  that  fracture  of  both  bones  at  the  same  level 
is  commonly  observed,  and  the  reverse  in  fracture  from  contrecoup. 

The  nature  of  the  displacement  will  depend  upon  the  direction  of 
the  line  of  fracture  and  the  sort  of  force  producing  it.  When  the 
line  is  transverse,  there  will  be  little  else  than  perhaps  some  lateral 
deflection  of  the  ends  of  the  fragments  in  opposite  directions,  and  the 
limb  not  shortened.  When  it  is  oblique,  which  it  generally  is,  and  in 
a direction  downwards  and  forwards,  the  lower  fragment  will  be  drawn 


Fig.  425. 


Fig.  426. 


Fractures  of  the  tibia  aud  fibula. 


FRACTURE  OF  THE  TIBIA  AND  FIBULA. 


481 


upwards  by  the  muscles  of  the  calf  of  the  leg,  and  thus  produce  slight 
shortening.  In  this  instance  the  top  of  the  superior  piece  will  project 
in  front  beneath  the  skin,  sometimes  will  perforate  it,  rendering  the  in- 
jury compound.  Angular  displacement  anteriorly  is  also  seen  in  certain 
cases,  and  is  caused  by  the  contraction  of  the  quadriceps  femoris  or 
the  gastrocnemius,  and  sometimes  by  the  weight  of  the  foot  alone,  the 
former  muscle  acting  with  greater  energy  as  the  fracture  is  nearer  the 
knee.  Should  the  foot  be  twisted  inwards  or  outwards,  the  lower 
fragment  will  be  rotated  upon  the  upper. 

Symptoms. — The  symptoms  denotive  of  fracture  of  the  leg  are  pre- 
ternatural mobility  at  the  seat  of  fracture,  deformity  when  the  foot  is 
raised,  irregularity  upon  the  anterior  border  of  the  tibia  and  outer 
edge  of  fibula  when  the  fingers  are  run  along  them,  slight  shortening, 
and  crepitus  evolved  by  rotating  the  leg.  The  patient  cannot  bear 
his  weight  upon  the  limb,  and  efforts  to  do  so  cause  excruciating  pain. 

Prognosis. — Fracture  of  the  tibia  and  fibula  will  generally  unite 
well  in  about  thirty  days  without  any  difficulty,  while  in  certain  cases 
it  may  be  delayed  a much  longer  period.  Compound  and  comminuted 
fractures  are  liable  to  become  complicated  with  inflammation  and  sup- 
puration, erysipelas,  necrosis  of  the  ends  of  the  fragments,  and  in  one 
case  I saw  tetanus  occur  on  the  seventh  day  and  kill  the  patient.  It 
occasionally  happens,  in  some  of  these  complicated  fractures,  that  a 
crooked  leg  will  result  in  spite  of  the  best  treatment. 

Treatment. — The  treatment  of  this  injury  has  been  variously  con- 
ducted, as  regards  the  position  of  the  limb  and  the  construction  of 
apparatus  for  retaining  the  ends  of  the  bones  in  contact  while  con- 
solidation is  being  effected.  Most  surgeons  prefer  the  straight  position 
of  the  limb  as  meeting  more  fully  all  the  indications  presented  in  this 
fracture,  and  either  do  or  do  not  make  extension  and  counter-extension, 
according  to  their  views  of  the  necessities  of  the  case. 

One  of  the  simplest  dressings,  with  the  leg  in  the  straight  position, 
and  without  making  extension  or  counter-extension,  is  prepared  in 
the  following  manner : Spread  upon  a pillow,  on  which  the  leg  is  to 
:repose,  a piece  of  cotton  cloth  long  enough  to  reach  from  the  lower 
third  of  the  thigh  to  the  ankle,  and  sufficiently  wide  to  encircle  the 
limb  twice;  over  this  lay  as  many  strips  of  the  same  material  as  will 
reach  from  the  ankle  to  the  knee,  each  strip  being  imbricated  and 
sufficiently  long  to  go  around  the  limb  once  and  overlap  two  inches 
upon  either  side;  the  leg  is  now  placed  upon  the  dressings,  and 
inclosed  by  bringing  the  strips  around  it  in  the  same  manner  as  in 
the  bandage  of  Scultetus.  Three  cushions  of  oat-chaff  or  long  com- 
presses of  lint  are  placed  upon  each  side  and  front  of  the  limb,  and 
held  in  place  while  an  assistant  makes  extension  from  the  foot,  to 
bring  the  displaced  fragments  end  to  end ; the  surgeon  will  then  roll, 
ip  in  the  splint-cloth,  from  its  ends  towards  the  leg,  two  splints  of  the 
same  length  as  the  cloth,  and  bring  them  firmly  against  the  cushions,, 
md  place  a narrow  splint  in  front  of  the  leg;  three  strips  of  bandage 
ire  now  applied,  to  bind  the  whole  together.  To  prevent  the  foot 
rom  falling  to  either  side,  a cravat  may  be  folded  around  the  foot, 
md  its  ends  pinned  to  the  splint-cloth.  Instead  of  wooden,  splints, 


482 


SPECIAL  FRACTURES. 


wheat-straw  may  be  rolled  up  in  bundles  and  used  for  the  same  pur- 
pose as  the  splints. 

This  apparatus  will  be  found  exceedingly  convenient  in  cases  of 
emergency,  and  I was  in  the  habit  of  employing  it  often  during  the 
late  war,  under  circumstances  where  other  more  appropriate  means 
were  not  attainable. 

The  fracture-box  is  another  simple  contrivance,  and  will  be  found 
to  answer  well  in  most  cases.  It  consists,  as  seen  in  Fig.  427,  of  an 

oblong  wooden  box  of  four  sides, 
reaching  from  a little  above  the  knee 
to  the  sole  of  the  foot ; the  lateral 
sides,  six  or  seven  inches  wide,  are 
attached  to  the' bottom  by  means  of 
hinges,  which  permit  them  to  be 
raised  or  lowered,  as  desired;  the 
fourth  side  projects  upwards,  and 
serves  the  purpose  of  a footboard. 

In  employing  the  box,  the  sides 
are  lowered  to  a level  with  its  bot- 
tom; a pillow  is  placed  upon  it,  and  the  leg  upon  the  pillow;  extension 
is  now  made  until  the  fracture  is  reduced,  Avhen  the  sides  of  the  box 
are  raised  and  the  edges  of  the  pillow  pressed  evenly  upon  the  lateral 
surfaces  of  the  leg.  Three  strips  of  bandage  are  passed  around  the 
box,  to  bind  it  together,  and  knotted  upon  one  of  its  edges ; the  foot 
is  held  to  the  footboard  by  a strip  of  bandage. 

If  there  is  any  discharge  from  the  leg,  to  prevent  it  soiling  the 
pillow,  a piece  of  oiled  silk  may  be  interposed  between  them. 

The  fracture-box  has  been  highly  recommended  by  Dr.  J.  Rhea  Bar- 
ton in  compound  fracture,  but  he  employs,  instead  of  the  pillow,  a 
quantity  of  bran,  which  should  surround  and  cover  the  leg.  This 
dressing  possesses  the  advantages  of  affording  the  limb  uniform  sup- 
port in  every  direction,  does  not  produce  excoriation  or  ulceration  of 
the  heel,  and  keeps  the  flies  from  depositing  their  ova  in  the  suppu- 
rating wound,  which  they  are  exceedingly  apt  to  do  in  hot  weather. 
I used,  in  the  same  manner,  flue  pine  sawdust  in  a case  of  compound 
fracture  of  both  legs,  and  believe  it  equally  as  serviceable  as  the  bran, 
over  which  it  possesses  the  merit  of  being  more  absorbent,  and,  I 
believe,  forms  a cooler  bed  for  the  leg  to  repose  in,  and  does  not  be- 
come sour. 

The  leg  should  be  inspected  daily,  and  any  tendency  to  angular 
deformity  corrected  by  proper  compresses  placed  beneath  the  tendo- 
Achillis  and  heel.  It  should  not  be  forgotten,  however,  that  these 
compresses  may  produce  injurious  pressure  upon  these  parts,  and 
cause  ulceration,  a result  only  to  be  avoided  by  either  removing  the 
pressure  entirely,  or  making  it  as  uniform  and  soft  as  possible. 

Should  it  be  deemed  advisable  to  make  compression  upon  the  leg, 
or  to  facilitate  the  application  of  lotions  of  the  acetate  of  lead  or  other 
dressings,  the  bandage  of  Scultetus,  applied  directly  to  the  limb,  will 
answer  better  than  anything  else. 

If  the  lower  end  of  the  upper  fragment  will  project  forwards  in 


Fig.  427. 


The  fracture-box. 


FRACTURE  OF  THE  TIBIA  AND  FIBULA. 


483 


spite  of  these  efforts  of  the  surgeon,  he  will  sometimes  succeed  in 
keeping  it  in  position  by  bringing  pressure  to  bear  upon  it  by  the 
tourniquet  of  Petit,  its  pad  being  placed  over  the  bone,  and  the  strap 
buckled  around  the  box. 

After  the  dressings  are  applied  according  to  the  requirements  of 
the  case,  some  degree  of  general  movement  of  the  leg  may  be  obtained, 
without  affecting  the  relations  of  the  fragments  of  bone  to  each  other, 
by  swinging  the  fracture-box  from  a horizontal  bar  supported  above 
it  by  a frame,  as  seen  in  Fig.  428. 


Fig.  428. 


A better  form  of  a swinging  apparatus  is  seen  in  Fig.  429,  in  which 
the  cradle  is  supported  upon  the  horizontal  bar  by  two  little  wheels, 

Fig.  429. 


Another  form  of  suspensory  apparatus  for  fracture  of  the  leg. 


iat  permit  vertical  as  well  as  lateral  motion,  and  thus  remove  the 
■anger  of  the  upper  fragment  being  thrust  over  the  lower. 

The  “anterior  splint”  of  Prof.  1ST.  R.  Smith  will  also  be  found  an 


484 


SPECIAL  FRACTURES. 


admirable  means  in  many  cases  of  compound  fracture  of  the  leg.  It 
permits  the  seat  of  fracture  to  be  constantly  exposed  to  the  examina- 
tion of  the  surgeon,  does  away  with 
all  undue  pressure  and  its  results 
upon  the  heel,  and,  lastly,  facilitates 
the  cleansing  and  dressing  of  the 
parts. 

The  starch,  gutta  percha,  plaster, 
or  dextrine  bandage  may  be  em- 
ployed in  simple  fracture  of  the  leg 
after  two  or  three  days,  'when  the 
inflammation  and  tumefaction  have 
subsided.  I usually  apply  this 
bandage  in  almost  all  cases  of  frac- 
tures of  the  leg,  when  the  discharge 
and  wounds,  if  any,  have  been  got- 
ten rid  of  in  other  apparatus,  and 
permit  the  patient  to  go  about  upon 
crutches.  For  safety,  I always  use 
a bi waived  apparatus,  padded  with 
cotton-batting,  and  secured  to  the 
leg  and  foot  by  the  roller  bandage. 
In  this  arrangement  the  parts  may 
be  examined  at  any  time  without 
disturbing  the  limb,  which  is  permitted  to  repose  in  one  of  the  sec- 
tions while  the  opposite  one  is  removed. 

In  those  instances  of  fracture  where  the  fragments  persistently  over- 
lap, it  has  been  recommended  by  some  surgeons  to  employ  extension 
and  counter-extension.  Several  plans  have  been  devised  for  this  pur- 
pose. Dr.  James  Hutchinson  contrived  an  apparatus  that  has  been 
much  employed  in  this  country,  but  now  almost  abandoned,  and  very 


Fig.  430. 


Starched  apparatus  in  fracture  of  the  leg. 


Fig.  431. 


justly,  inasmuch  as  bad  consequences  were  frequently  observed  tofol 
low  the  constriction  exercised  by  the  band  encircling  the  leg  belo^ 
the  knee. 


FRACTURE  OF  THE  TIBIA  AND  FIBULA. 


1 485 


This  apparatus  consists  of  two  side-splints,  extending  from  a little 
above  the  knee  to  a point  three  or  four  inches  beyond  the  sole,  con- 
nected below  by  a transverse  piece  fitting  into  mortises  at  their  ends. 
The  proximal  ends  of  the  splints  are  perforated  with  holes  for  the 
counter-extending  bands.  Its  application  requires  the  leg  to  be  enve- 
loped in  a bandage  of  Scultetus,  and  placed  upon  a pillow;  tapes  are 
then  laid  upon  each  side  of  the  leg  and  confined  by  a roller  beneath 
the  knee,  and  a gaiter  placed  upon  the  foot  or  a cravat  made  to  encir- 
cle the  ankle  for  making  the  extension.  Cushions  are  placed  inside  of 
the  splints,  the  counter-extending  tapes  passed  through  the  apertures 
in  their  upper  extremities  and  tied,  when  the  fracture  is  reduced,  and 
maintained  so  by  fastening  the  ends  of  the  extending  cravat  to  the 
cross-bar.  Two  or  three  pieces  of  bandage  are  now  tied  around  the 
splints  and  leg  to  bind  the  whole  together. 

Dr.  Neill  employs  extension  and  counter-extension  in  the  following 
manner : “For  simple  fracture  of  both  bones  of  the  leg,  attended  with 


Fig.  432. 


shortening  and  deformity,  not  easily  overcome,  the  limb  should  be 
.placed  in  a long  fracture-box  (Fig.  432),  with  sides  extending  as  high 
is  the  middle  of  the  thigh,  and  a pillow  should  be  used  for  com- 
presses. 

“The  counter-extension  is  made  by  strips  of  adhesive  plaster,  one 
nch  and  a half  in  breadth,  secured  on  each  side  of  the  leg  below  the  ’ 
£nee,  and  above  the  seat  of  fracture  by  narrow  strips  of  plaster  ap- 
plied circularly.  The  end  of  the  counter-extending  strips  may  then 
ie  secured  to  holes  in  the  upper  end  of  the  sides  of  the  fracture-box, 
)y  which  the  line  of  the  counter-extension  is  rendered  nearly  parallel  with 
'he  limb.'n 

Extension  is  made  with  adhesive  strips  in  the  usual  manner. 


Fig.  433. 


Neill’s  apparatus  for  compound  fractures  of  the  leg. 


In  compound  fractures,  where  extension  and  counter-extension  are 
equired,  and  certain  dressings  to  the  injured  parts,  he  employs  the 


486  * 


SPECIAL  FRACTURES. 


apparatus  seen  in  Fig.  433.  It  differs  from  the  preceding  apparatus, 
in  that  its  sides  are  sawn  through  at  the  knee,  and  the  lower  sections 
fastened  to  the  bottom  by  hinges,  so  that  they  may  be  lowered  and 
expose  the  leg  without  disturbing  the  tension  of  the  extending  and 
counter-extending  bands. 

Mr.  Fergusson  is  very  favorably  impressed  with  the  utility  of  aninstru- 
ment  constructed  by  Mr.  W eiss,  of  London.  It  yields  ample  support  to 


Fig.  434. 


the  limb;  having  a footboard  prevents  the  toes  from  turning  inwards 
or  outwards ; is  cheap,  light,  and  portable,  and  with  slight  modifica- 
tion may  be  employed  in  the  treatment  of  fracture  of  the  patella  or 
thigh. 

“The  bars  and  foot-piece  consist  of  iron,  the  screws  of  brass;  the 
long  bar  is  of  an  average  length,  to  extend  between  the  knee,  and  be- 
yond the  sole  of  the  foot ; the  board  is  so  attached  that  it  can  be  slid 
upwards  or  downwards  at  will,  and  then  be  fastened  by  the  side  screws; 
it  can  also  be  moved  in  a lateral  direction,  so  as  to  evert  or  invert  the 
toes ; and,  moreover,  it  can  be  placed  at  such  a distance  from  the  splint 
at  the  ankle  as  may  be  found  best  suited  to  the  thickness  of  the 
patient’s  limb.  The  cross-bar  below  prevents  the  member  from  rolling 
outwards  or  inwards,  and  by  means  of  the  screw  the  side-splint  and 
foot  may  be  raised  or  depressed,  as  may  be  found  most  convenient. 
The  bar  may  be  attached  to  the  screw  at  the  knee,  where  it  will  some- 
times be  found  to  answer  best ; or  two  may  be  used,  one  above  and 
one  below,  each  being  of  service  to  raise  the  part  over  it  to  any  required 
height.  In  the  cut  a small  portion  of  another  side-bar  is  exhibited ; 
this  is  of  the  same  size  and  shape  as  that  above  described,  and  is  in- 
tended to  act  as  a thigh-splint  in  cases  of  fracture  here,  or  when  it 
may  be  desired  to  apply  extension  in  fracture  of  the  leg.” 

The  accompanying  drawing  (Fig.  435)  shows  the  manner  in  which 
the  apparatus  is  applied.  The  side-splint  is,  however,  wider  than  that 
described  above,  a modification  which  Mr.  Fergusson  has  deemed 
necessary  in  certain  cases. 

Dr.  Welsh’s  veneered  gutta-percha  spliuts  (Fig.  436)  for  fracture  of 
the  leg  are  also  a useful  contrivance,  giving  equable  support  to  the 
whole  leg  and  foot,  and  will  be  found  of  especial  value  in  those  cases 
of  fracture  involving  the  knee  and  ankle-joints. 

Dr.  Bauer,  of  New  York,  has  also  devised  iron  wire  splints  (Fig.  437), 
which  not  only  sustains  the  parts  accurately,  but,  according  to  this  gen- 


FRACTURE  OF  THE  TIBIA  AND  FIBULA. 


487 


Fig.  435. 


tleman.  possess  the  further  merit  of  permitting  the  insensible  perspira- 
tion to  escape  freely  through  its  meshes,  and  allowing  the  applications 


Fig.  436. 


Welsh’s  apparatus  for  fractured  leg. 


of  water-dressings  without  impairing  the  strength  of  the  splint.  With 
proper  care,  however,  application  of  remedial  agents  may  be  made  as 


Fig.  437. 


Bauer’s  apparatus  for  fractured  leg. 


well  while  using  other  forms  of  splints  as  those  of  wire — and  as  these 
are  always  covered  upon  those  surfaces  iu  contact  with  the  skin  with 
cotton-batting,  or  other  absorbent  materials,  the  perspiratory  secre- 
tions are  readily  taken  up. 

As  the  displacement  of  the  fragments  results  either  from  the  direc- 


488 


SPECIAL  FRACTURES. 


tion  of  the  line  of  fracture  or  muscular  contraction,  it  has  been  recom- 
mended by  some  surgeons  to  flex  the  limb,  and  thereby  relax  the  mus- 
cles causing  the  displacement,  especially  when  the  line  of  fracture  is 
from  above  downwards  and  from  before  backwards.  Mr.  Erichsen  says, 
that  in  these  cases  the  bones  may  usually  be  got  into  excellent  posi- 
tion by  flexing  the  thigh  well  upon  the  abdomen,  and  the  leg  upon 
the  thigh,  so  that  the  heel  nearly  touches  the  nates,  and  then  laying 
the  limb  on  its  outer  side,  on  a wooden  leg-splint,  provided  with  a pro- 
per foot-piece,  and  keeping  it  fixed  in  this  position. 

During  the  war,  a large  number  of  cases  of  compound  fracture 
of  the  tibia  and  fibula  coming  under  my  care,  I placed  five  with  the 
leg  in  a bent  position  upon  Pott’s  splint.  (Fig.  438.)  I succeeded  well 


Fig.  438. 


Pott’s  angular  splint  for  fractured  leg. 


in  keeping  the  fragments  in  apposition,  and  four  were  cured  with  an 
average  shortening  of  half  an  inch  ; in  the  fifth  there  was  no  appre- 
ciable shortening. 

The  mode  of  dressing  pursued  was  the  employment  of  an  outside 
splint  about  seven  inches  wide,  reaching  from  above  the  knee  to  the 
sole  of  the  foot,  with  an  angular  projection  from  this  point  to  the  tips 
of  the  toes  to  support  the  foot.  This  splint  was  well  padded  with  cot- 
ton-batting, with  an  excavation  for  the  external  malleolus,  so  as  to 
relieve  it  from  all  pressure.  This  was  placed  upon  the  outside  of  the 
limb  so  as  to  bring  the  inner  border  of  the  great  toe  in  line  with  the 
inner  border  of  the  patella,  the  thigh  having  been  previously  bent 
upon  the  abdomen,  and  the  leg  at  right  angles  with  the  thigh ; upon 
the  inside  of  the  leg  a padded  pasteboard  splint  was  put,  extending 
from  the  knee  to  the  upper  border  of  the  internal  malleolus ; a roller 
bandage  was  now  applied  from  the  toes  upwards,  leaving  the  seat  of 
the  fracture  uncovered. 

If  the  parts  needed  support,  I used  the  bandage  of  Scultetus,  applied 
directly  to  the  leg  from  the  ankle  to  the  knee,  and  if  there  was  much 
discharge,  I interposed  a piece  of  oiled  silk  between  the  limb  and 
splint  to  protect  the  latter. 

When  the  apparatus  was  completed  the  limb  was  placed  upon  its 
outer  side,  to  which  the  body  was  also  inclined,  though  the  patients 


FRACTURE  OF  THE  TIBIA  AND  FIBULA.  489 

often  changed  this  position  to  dorsal  decubitus  without  disturbing  the 
relations  of  the  fragments. 

The  double-inclined  plane,  with  the  footboard  attached,  already  de- 
scribed, may  be  also  employed  in  the  treatment  of  this  fracture. 

Mr.  Fergusson  gives  decided  preference  to  the  apparatus  of  Mr. 
M’lntyre,  as  modified  by  Mr.  Liston.  It  consists  of  a thigh  and  leg- 
piece  of  sheet  iron,  and  a footboard  of  wood ; the  former  are  joined 


Fig.  439. 


M'lntyre’s  apparatus  for  fractured  leg. 


to  each  other  by  a couple  of  hooks,  and  a screw,  which  is  so  placed 
that  the  two  plates  can  be  set  to  any  angle  at  which  it  may  be  desira- 
ble to  bend  the  knee,  and  the  footboard  is  affixed  in  such  a manner 
that  it  may  be  slid  upwards  or  downwards  to  suit  the  length  of  the 
leg,  and  fastened  by  a side-screw  in  any  position  that  may  be  desired. 
At  the  lower  end  of  the  machine  there  is  a cross-plate  of  iron,  which 
is  so  attached  that,  in  the  event  of  the  foot  being  raised  or  depressed, 
it  will  always  rest  flatwise  on  the  mattress,  or  a board  placed  at  the 
foot  of  the  bed  for  the  purpose  of  supporting  it. 

The  instrument  is  applied  by  placing  upon  it  suitable  cushions  upon 
which  to  repose  the  limb  after  the  fracture  has  been  reduced  ; intro- 
duce compresses  to  rectify  any  malposition  of  the  fragments  if  that 
should  exist,  and  to  equalize  the  pressure  over  the  leg ; then  apply  a 
roller  bandage  from  the  toes  upwards,  leaving  the  seat  of  injury  in- 
creased, if  the  fracture  is  compound,  and  attended  with  discharge. 
Extension  may  be  made  according  to  the  necessities  of  the  case. 

From  the  construction  of  this  apparatus  it  may  be  used  either  as  a 
straight  splint  or  as  a double-inclined  plane. 

There  is  sometimes  great  difficulty  encountered,  in  oblique  fracture 
from  above  downwards,  and  from  before  backwards,  in  keeping  the 
i lower  point  of  the  upper  fragment  in  position;  it  projects  beneath  the 
skin,  and  may  perforate  it,  thus  rendering  an  otherwise  simple  fracture 
compound.  Malgaigne  has  proposed  an  apparatus  (Fig.  440)  to  remedy 
. this.  It  consists  of  an  arc  of  steel  sufficiently  long  to  span  three-fourths 
of  the  circumference  of  the  leg;  through  its  centre  a sharp-pointed  metal- 
lic screw  works,  which  also  slides  in  a fenestrum,  so  that  its  position  may 
’ be  varied  in  such  a manner  that  the  point  may  always  be  forced  against 
the  bone  perpendicular  to  the  shaft  of  the  tibia.  The  extremities  of 
the  arc  have  two  horizontal  mortises  for  the  attachment  of  a strap. 
The  instrument  is  applied  by  placing  the  limb  upon  a well-padded 


490 


SPECIAL  FRACTURES, 


double-inclined  plane;  the  arc  is  put  over  the  seat  of  fracture,  and 
then  secured  in  position  by  the  strap  buckling  around  the  splint.  By 


Fig.  440. 


turning  the  head  of  the  screw  the  sharp  point  is  pressed  against  and 
into  the  tip  of  the  projecting  fragment. 


Fig.  441. 


Malgaigne  says  that  the  patient  feels  moderate  pain  at  the  moment 
the  puncture  occurs,  but  that  it  soon  diminishes.  The  limb  should  be 
kept  quiet,  and  the  instrument  will  remain  implanted  in  the  bone 
fourteen,  twenty,  and  even  thirty-six  days  without  determining  sup- 
puration, inflammation,  or  even  redness.  "When  the  apparatus  is 
removed  the  puncture  in  the  skin  cicatrizes  in  twenty-four  hours. 

Fracture  of  the  Tibia.  Causes. — Fracture  of  the  tibia  is  gene- 
rally caused  by  direct  violence,  such  as  heavy  blows,  the  kicks  of  a 
horse,  &c.  The  weight  of  the  body  coming  upon  the  sole  of  the  foot, 
as  occurs  in  jumping  from  a height,  is  the  indirect  cause  sometimes 
observed.  The  point  of  fracture  may  be  in  the  shaft  or  at  either 
extremity;  its  direction,  in  the  former  instance,  is  ordinarily  trans- 
verse; in  the  latter,  oblique,  and  not  unfrequently  runuing  into  the 
knee  or  ankle-joints.  Fracture  of  the  shaft  is  seen,  in  a majority  of 
cases,  in  its  middle  third. 

Symptoms. — As  the  fibula  remains  intact,  it  serves  as  a sort  of 
splint  to  the  tibia,  so  that  little  or  no  displacement  can  occur.  The 
symptoms  will  be  obscure,  though,  if  the  case  is  seen  early,  some 
irregularity  may  be  felt  upon  the  surface  of  the  tibia,  and  perhaps 
obscure  crepitus  developed. 


FRACTURE  OF  THE  FIBULA. 


491 


Prognosis. — F racture  of  the  shaft  will  unite  promptly  without  de- 
formity, while  in  those  cases  where  the  knee  or  ankle-joints  are 
involved,  anchylosis  should  always  be  feared. 

Treatment. — When  the  fracture  is  oblique  from  above  downwards 
and  from  behind  forwards,  penetrating  the  knee-joint,  Sir  A.  Cooper 
recommended  that,  in  order  to  relax  the  quadriceps  extensor,  which 
throws  the  upper  fragment  forwards,  the  limb  be  placed  in  a straight 
position,  and  a pasteboard  splint  be  applied,  embracing  the  lower 
third  of  the  thigh,  knee,  and  upper  part  of  the  leg. 

In  the  contrary  case,  where  the  line  of  fracture  is  in  a reverse  direc- 
tion, the  deformity  is  caused  by  the  gastrocnemius  drawing  up  the  lower 
fragment,  and  therefore  the  limb  should  be  placed  upon  a double- 
inclined  plane  to  relax  this  muscle,  while  the  weight  of  the  leg  will 
act  as  an  extending  force.  In  regard  to  this  latter  point,  however,  it 
may  be  added,  that  extension  in  these  cases  is  quite  unnecessary. 

A simple  straight  splint  will  usually  answer,  in  a majority  of  cases, 
all  the  indications  presented  by  a fracture  of  the  shaft  of  the  tibia. 

An  oblique  fracture  into  the  ankle-joint,  attended  with  eversion  or 
inversion  of  the  foot,  requires  the  application  of  a splint  in  the  manner 
directed  for  fracture  of  the  fibula,  being  put  upon  that  side  of  the 
limb  opposite  the  direction  in  which  the  foot  is  deflected;  that  is,  if 
the  foot  is  everted,  place  the  splint  on  the  inside  of  the  leg,  and  the 
reverse  if  it  is  inverted. 

Prof.  Gross  recommends  a tin  case,  accurately  fitting  the  foot  and  leg, 
and  extending  above  the  knee.  (Fig.  442.)  It  is  padded,  and  fastened 


Fig.  442. 


Fig.  443. 


Wire  splint. 


to  the  limb  by  a roller  bandage.  The  wire  splint  seen  in  Fig.  443 
1 is  also  an  elegant  and  efficient  contrivance  for  such  cases,  and  it  is  the 
' one  I am  most  in  the  habit  of  employing. 

Fracture  of  the  Fibula. — Fracture  of  the  fibula  may  occur  at 
any  part  of  its  extent,  though  it  is  by  far  most  common  in  the  lower 
!■  fourth.  In  the  upper  three-fourths  the  fragments  will  be  sustained  bv 
the  tibia,  and  therefore  little  displacement  can  occur.  The  symptoms 
are  pretty  much  those  of  a similar  injury  of  the  tibia,  and  the  treatment 


SPECIAL  FRACTURES. 

requires  the  leg  to  be  kept  quiet  in  simple  straight  splints 
or  a starched  apparatus  until  the  consolidation  is  effected. 

In  the  lower  fourth  of  the  bone  (Fig.  444)  the  fracture 
is  quite  another  thing,  both  as  regards  its  prognosis  and 
treatment. 

Causes. — In  the  majority  of  cases  the  fracture  will  be 
found  to  result  from  indirect  force — falls  upon  the  feet, 
false  steps,  &c.;  sometimes,  also,  blows  upon  the  outer 
edge  of  the  leg  will  produce  the  same  result. 

The  mechanism  of  the  fracture  depends  upon  the 
position  of  the  foot  at  the  time  the  weight  of  the  body 
comes  upon  it,  for  if  this  is  everted,  the  os  calcis  being 
turned  outwards,  will  press  the  lower  extremity  of  the 
fibula  upwards,  and  a fracture  will  result  in  the  fibula 
about  three  inches  above  the  lower  extremity ; on  the 
other  hand,  the  weight  of  the  body  falling  upon  the  in- 
verted foot,  will  cause  the  astragalus  to  rotate  outwards 
against  the  external  malleolus,  and  break  the  bone  near 
the  same  point. 

The  fracture  is  usually  complicated  with  a rupture  of  the  deltoid 
ligament,  or  a fracture  of  the  lip  of  the  inner  malleolus,  or  a fracture 
of  the  entire  inner  malleolus,  the  line  of  separation  occurring  from 
without  inwards  and  downwards. 

Symptoms. — The  symptoms  will  vary  according  to  the  nature  of 
these  complications.  In  the  first  case,  that  of  fracture  of  the  fibula  with 
rupture  of  the  internal  lateral  ligament,  the  pain  will  be  severe,  and 
the  ankle  much  swollen ; the  patient  cannot  bear  his  entire  weight 
upon  the  foot,  which  will  be  slightly  everted ; a depression  will  be 
felt  over  the  seat  of  fracture,  and  indistinct  crepitus  may  be  evolved 
by  moving  the  foot.  When  the  tip  of  the  malleolus  is  broken  off,  in 
connection  with  these  symptoms,  a depression  will  exist  above  the 
detached  fragment.  Lastly,  in  these  cases,  when  the  inner  malleolus 
is  obliquely  fractured,  the  toes  will  be  everted,  the  foot  much  rotated 
out,  and,  when  grasped  in  the  hand,  may  be  readily  moved  in  any 
direction,  and,  at  the  same  time,  these  motions  will  emit  distinct 
crepitus.  The  malleoli  will  be  widely  separated,  giving  the  ankle  the 
appearance  of  an  increased  width. 

Prognosis. — All  of  these  injuries  will  be  attended  with  more  or  less 
stiffness  of  the  joint  after  the  apparatus  is  removed,  which  in  a few 
months  will  generally  disappear.  In  one  case  that  came  under  my 
care,  where  the  inner  malleolus  was  also  fractured,  after  the  bones 
had  united  without  deformity,  and  considerable  motion  was  restored 
to  the  joint,  the  patient  could  not,  at  the  lapse  of  nine  months,  bear  his 
weight  upon  the  foot  without  the  assistance  of  an  apparatus  I subse- 
quently contrived  for  him. 

Compound  fractures  from  direct  violence  frequently  require  ampu- 
tation, and  will  generally  result,  if  the  foot  is  saved,  in  anchylosis.' 

Treatment  of  fracture  of  the  lower  fourth  of  the  fibula. — If  there  is 
much  inflammatory  action,  lay  the  leg  in  an  easy  position  upon  a 
pillow,  and  apply  leeches,  cold  water- dressings,  or  other  antiphlogistics, 


492 

Fig.  444. 


Fracture  of  the 
fibula. 


FRACTURE  OF  THE  TARSAL  BONES. 


493 


and,  when  the  swelling  has  abated,  apply  the  apparatus  required,  of 
which  none  are  better  than  that  of  Dupuytren  when  the  foot  is  rotated 
either  outwards  or,  as  it  sometimes  is,  inwards.  (Fig.  446.) 

The  splint,  which  is  to  be  placed  upon  that  side  of  the  limb  opposite 
to  that  to  which  the  foot  is  turned,  should  extend  from  the  knee  to 
fourjnohes  bevond  the  foot,  about  three  wide  and  half  an  inch  thick; 
a^ahTwirtrTh^hick  end  downwards,  must  be  interposed  between  the 
splint  and  leg,  and  reach  from  the  knee  to  the  upper  border  of  the 


Fig.  445. 


Dapuytren’s  splint  modified. 


malleolus.  "With  a roller  bandage  confine  the  splint  to  the  leg  above, 
and  with  another  roller  secure  the  foot  by  turns  having  the  form  of  a 
figure  8,  which  will  draw  the  foot  in  an  opposite  direction  to  the  dis- 
placement, the  lower  thick  end  of  the  pad  pressing  against  the  tibia, 
acting  as  a fulcrum. 


Fig.  446. 


Dupuytren’s  apparatus  for  fractured  fibula. 


The  form  of  Dupuytren’s  splint  is  somewhat  modified,  as  seen  in 
Fig.  445,  by  having  two  retiring  angles  or  notches  at  its  lower  ex- 
tremity, and  two  holes  at  the  upper  one  for  tapes  to  pass  in  fixing  the 
pad  to  the  splint.  The  difference  of  its  application  consists  in  passing 
the  lower  convolutions  of  the  bandage  around  the  ankle  and  notches. 

The  apparatus  should  be  removed  in  three  or  four  weeks,  and 
passive  motion  impressed  upon  the  joint  daily,  aided  by  stimulating 
and  oily  frictions. 

Fracture  of  the  Tarsal  Bones. — The  astragalus  and  calcaneum 
are  sometimes  broken  by  crushing  violence  applied  to  the  foot,  but 
the  former  is  most  often  broken  by  persons  falling  from  a height 
alighting  upon  their  feet,  and  the  latter  by  great  muscular  action,  as 
when  a person  falling  makes  violent  efforts  to  save  himself,  or  in 
jumping. 

The  other  tarsal  bones  are  fractured  by  the  foot  being  crushed  by 
heavy  objects. 

The  line  of  fracture  may  pass  through  the  astragalus  in  most  any 
direction — antero-posteriorly,  horizontally,  or  transversely.  In  the  os 
calcis  it  is  seated  usually  in  the  neck  of  the  bone,  or  sometimes  be- 
neath the  astragalus. 

Malgaigne  has  drawn  attention  to  a species  of  fracture  occurring  in 


494 


SPECIAL  FRACTURES. 


Fig.  447. 


these  two  bones  attended  with  comminution  and  impaction  of  the  upper 
fragment  into  the  lower,  causing  a separation  of  the  malleoli  and  an 
increased  breadth  of  the  foot. 

From  the  close  connection  of  the  tarsus  by  ligaments  there  can 
scarcely  occur  any  displacement  of  the  fragments  except  in  the  calca- 
neum,  when  the  fracture  is  seated  posteriorly  to  the  lateral  ligaments 
between  them  and  the  insertion  of  the  tendo-Achillis,  in  which  in- 
stance the  posterior  fragment  will  be  drawn  upwards. 

Symptoms. — The  parts  will  generally  be  found  much  swollen  and 
painful,  the  patient  cannot  stand  upon  the  foot,  and  sometimes  obscure 
crepitus  may  be  elicited  by  rubbing  the  fragments  together.  If  the 
tuberosity  of  the  os  calcis  is  broken  off  the  connection  of  the  gastroc- 
nemius will  draw  the  detached  piece  upwards,  and  the  heel  will  be 
shortened. 

Treatment. — The  mechanical  requirements  in  fracture  of  the  tarsus 
are  few ; the  foot  must  be  placed  upon  a pillow,  and  inflammatory 
action  combated  by  suitable  remedies.  The  displaced  tuberosity  of 
the  os  calcis  may  be  drawn ; the  leg  bent  upon  the  thigh  and  the  foot 
extended  to  relax  the  gastrocnemius  muscles,  and  the  slipper  of  Mon- 
roe, described  at  page  495,  applied  to  retain  this  position,  or  the  appara- 
tus of  Mr.  Lonsdale,  which  consists  of  a footboard 
somewhat  shorter  than  the  sole,  to  the  distal  ex- 
tremity of  which  the  end  of  a shoe  is  nailed  to  re- 
ceive the  toes ; the  proximal  end  has  a ring  attached 
with  a long  strap.  The  apparatus  is  applied  in  this 
manner  : Draw  the  separated  fragment  down  to  the 
heel ; place  a compress  abo've,  and  confine  it  by  a 
few  turns  of  a roller ; now  flex  the  leg,  extend  the 
foot,  and  put  on  the  slipper;  carry  the  strap  over 
the  point  of  the  heel  up  the  back  of  the  leg  to  the 
inferior  part  of  the  thigh,  where  it  is  confined  by 
turns  of  a roller  bandage,  and  reflected  upon  itself 
to  have  a few  more  turns  applied,  w'hen  the  dressing 
is  complete  (Fig.  447). 

Fracture  of  the  Metatarsal  Boxes. — These 
bones  can  only  be  fractured  by  the  application  of 
crushing  violence;  there  is  usually  no  displacement 
of  the  fragments  from  their  close  connection  with 
one  another.  Sometimes,  however,  the  lower  frag- 
ments have  been  found  depressed  backwards  from 
the  force  of  the  injury  causing  the  fracture. 

Treatment. — If  any  displacement  should  exist  it 
must  be  corrected  by  pressure  with  the  finger; 
then  support  the  foot  upon  a pillow,  and  combat  local  inflammation. 

If  the  fragments  show  any  disposition  to  slip  away  from  the  natural 
position  in  Avhich  they  have  been  placed,  a splint  with  appropriate 
compresses  may  be  applied  to  the«sole  of  the  foot  and  secured  with  a 
roller  bandage. 

Fracture  of  the  Phalanges  of  the  Toes. — The  phalanges  are 
broken  by  heavy  bodies  falling  upon  them,  and  the  injury  is  such  as 


FRACTURE  OF  THE  PHALANGES  OF  THE  TOES.  495 


Fig.  448. 


often  to  demand  the  removal  of  the  toes  with  the  knife.  In  fracture 
of  the  phalanges  of  the  great  toe  the  irritation  is  such  at  times  as  to 
cause  inflammation  along  the  course  of 
the  lymphatics  to  the  groin.  If  a splint 
is  deemed  necessary,  one  covering  the 
whole  sole  of  the  foot,  made  of  wood, 
binder’s  board,  or  gutta  percha,  may  be 
employed,  to  which  the  toes  can  be  bound 
by  a narrow  roller. 

Rupture  of  the  Tendo-Achillis. — 

This  injury  results  always  from  muscular 
action  occurring  while  persons  are  in  the 
act  of  jumping. 

The  patient  feels  a crack  about  the 
ankle,  and  finds  himself  unable  to  extend 
the  foot ; with  the  fingers  an  interval  may 
be  felt  between  the  separated  ends  of  the 
tendon. 

Treatment. — The  treatment  consists  in 
bringing  the  ends  of  the  tendon  in  apposi- 
tion, and  retaining  them  until  union  takes 
place  between  them.  This  is  accomplished 
by  position — the  leg  is  flexed  upon  the 
thigh,  and  the  foot  extended  upon  the  leg ; 
the  slipper  of  Monroe  (Fig.  448)  may  be 
then  applied  in  this  manner : Put  on  the 
patient’s  foot  an  ordinary  slipper  having 
a strong  cord  attached  to  its  heel;  around 
the  lower  part  of  the  thigh  buckle  a broad  strap  also,  with  a cord;  now 
tie  the  two  cords  together,  and  the  apparatus  is  completed  (Fig.  448). 
The  anterior  ankle  splint  of  Monroe  and  the  apparatus  of  J.  L.  Petit 
are  also  excellent  contrivances  for  maintaining  the  leg  in  the  proper 
position. 


PART  IV 


DISLOCATIONS:  THEIR  REDUCTION,  DRESSINGS,  AND 

APPARATUS. 


CHAPTER  I. 

SPRAINS  OR  STRAINS. 

The  articulations  are  liable  to  be  violently  twisted,  tbeir  joint 
surfaces  separated,  and  the  ligaments  stretched,  or  even  ruptured, 
without  any  permanent  displacement  of  the  bones  entering  into  their 
composition;  these  injuries  are  popularly  knowm  as  sprains  or  strains. 

The  symptoms  are  sudden  and  often  severe  pain,  not  unfrequently 
accompanied  with  a feeling  of  faintness;  stiffness,  and  difficulty  in  exe- 
cuting the  natural  motions  of  the  joint,  about  which  there  is  more  or 
less  swelling  and-ecchymosis  from  extravasation  of  the  blood  into  the 
cellular  tissue,  tendinous  sheaths,  and  bursae.  This  swelling,  how- 
ever, may  occur  some  distance  from  the  joint,  over  the  junction  of  the 
muscular  with  the  tendinous  fibres,  where  laceration  most  frequently 
takes  place  when  the  muscles  are  forcibly  stretched. 

Effusion  of  serum  into  the  textures  near  the  injured  part,  and  an 
increased  secretion  of  synovia  into  the  cavity  of  the  joint,  may  alter 
its  contour  in  such  a manner  that,  without  a very  careful  examina- 
tion, the  injury  may  be  mistaken  for  a dislocation. 

The  chief  discriminating  feature  of  a sprain  is  the  absence  of  any 
displacement  of  the  bony  surfaces  entering  into  the  formation  of  the 
joint. 

Should  the  injury  be  very  severe,  to  the  foregoing  local  symptoms, 
especially  when  one  of  the  larger  joints,  as  the  knee,  is  involved, 
great  constitutional  disturbance  will  be  added ; which,  together  with 
acute  local  inflammation,  may  produce  dangerous,  if  not  fatal  conse- 
quences. All  the  joints  are  liable  to  sprains,  but  not  in  an  equal 
degree ; the  ankle,  wrist,  and  elbow  being  most  frequently  affected  : 
the  knee  and  hip  less  so;  while  they  are  rarely  ever  met  with  in  the 
shoulder.  The  vertebral  articulations,  though  so  strong  and  so  amply 
protected  with  large  muscles,  also  suffer  from  sprains. 

It  is  the  giuglymoid  class  of  joints  particularly  which  is  most  obnox- 
ious to  these  injuries;  and  a comparison  of  their  anatomical  construction 
with  that  of  the  enarthrodial  joints  will  readily  explain  why  this  is  so. 
In  the  first  place,  the  hinge- like  articulations  move  but  in  two  direc- 
tions, forwards  and  backwards  ; in  the  second,  they  are  bound  together 


SPRAINS  OR  STRAINS. 


497 


by  short,  strong,  and  thick  ligaments,  that  yield  very  little  to  an 
extraneous  force  tending  to  separate  the  joint  surfaces,  and  hence  they 
are  often  torn;  a circumstance  enabling  us  also  to  account  for  the 
greater  seriousness  of  these  sprains  than  those  of  the  enarthrodial  or 
ball-and-socket  joints,  which  have  a greater  range  of  motion,  thinner, 
weaker,  and  more  extensible  ligaments — conditions  that  concur  in 
conferring  upon  them  a greater  immunity  from  sprains  and  the  lace- 
ration of  the  ligaments. 

Of  all  the  joints,  the  ankle  suffers  most  often  from  this  sort  of  vio- 
lence, and  the  right  ankle  more  frequently  than  the  left  in  the  propor- 
tion of  three  to  one. 

The  injuring  force  acting  upon  the  ankle  will,  in  a majority  of 
cases  (twelve  to  one),  cant  the  foot  inwards,  and  produce  what  Dupuy- 
tren  called  an  external  sprain.  The  cause  of  this  difference  is  stated 
to  be  the  obliquity  of  the  superior  surface  of  the  astragalus,  which  is 
from  above  downwards,  and  from  within  outwards;  favored  also  by 
the  circumstance  that  abduction  of  the  foot  is  more  easy  and  extended 
than  adduction. 

The  spraining  of  the  ankle  by  the  movements  of  forced  flexion  or 
extension  is  more  rare  than  by  the  lateral  or  twisting  motions.  Some- 
times portions  of  the  bone  are  detached  with  the  tendons  and  liga- 
ments, and  add  much  to  the  seriousness  and  severity  of  a sprain. 

Often,  perhaps,  many  serious  diseases  of  the  synovial  membranes 
and  cartilages  may  be  traced  to  a violent  or  a badly-treated  sprain ; 
and  this  will  not  cause  surprise  when  the  extent  of  some  of  these 
injuries  is  considered;  the  tendons,  ligaments,  cellular  tissue,  blood- 
vessels, nerves,  muscles,  and  even  the  bone  itself,  participating  to  a 
greater  or  less  extent  in  the  mischief,  according  to  the  severity  of  the 
sprain  and  the  state  of  the  patient’s  constitution  at  the  time  of  the 
'injury. 

It  not  unfrequently  happens  that  even  when  the  more  serious 
symptoms  have  passed  away,  the  swelling  diminished,  and  some  mo- 
bility restored  to  the  joint,  it  still  remains  stiff  and  weak,  and  more 
than  ever  liable  to  sprains.  When  the  knee  is  sprained  by  a fall  or 
:misstep,  the  violence  is  usually  expended  upon  its  internal  lateral 
ligament,  while  the  swelling  will  be  found  upon  its  external  face. 

It  occasionally  happens  that  the  fascia  forming  the  sheaths  of  mus- 
cles and  tendons  is  ruptured,  and  permits  them  to  spring  outwards 
through  the  aperture.  This  form  of  accident  is  especially  observed 
in  the  quadriceps  extensor  of  the  thigh,  the  long  head  of  the  biceps, 
and  in  the  extensor  tendons  of  the  fingers. 

Causes. — The  causes  of  sprains  are  muscular  contractions,  falls, 
and  violent  or  exaggerated  motions  of  the  joints,  producing  forced 
extension,  flexion,  lateral  movements,  or  rotation. 

Prog-nosis. — Where  these  injuries  are  slight,  patients  readily  re- 
cover from  them ; although,  even  in  these  instances,  in  rheumatic 
subjects,  persistent  and  serious  symptoms  often  result. 

Severe  sprains  may  produce  paralysis,  atrophy,  muscular  rigidity, 
Tnd  chronic  arthritis,  the  latter  sometimes  demanding  amputation. 

The  greatest  diligence  should  be  exercised  in  making  out  a clear 

82 


498 


SPRAINS  OR  STRAINS. 


diagnosis,  before  any  plan  of  treatment  is  instituted.  The  manual 
examination  must  be  thorough  and  at  the  same  time  gentle,  that  no 
unnecessary  pain  may  be  inflicted  upon  the  patient. 

Sprains  have  been  very  frequently  confounded  with  dislocations; 
but  proper  attention  to  the  diagnostic  symptoms  will  generally  pre- 
vent any  such  occurrence.  It  will  be  well  to  mention  in  this  connec- 
tion, that  the  hip-joint  may  be  severely  sprained  by  the  slipping  of 
the  foot  outwards,  causing  forced  abduction  of  the  limb  and  stretching 
of  the  capsular  ligament,  which  may  lead  the  practitioner  astray  in 
supposing  a dislocation  downwards  and  forwards  into  the  thyroid 
foramen,  from  the  somewhat  analogous  character  of  the  symptoms  of 
the  two  injuries. 

Treatment. — In  robust  and  plethoric  patients,  in  whom  the  local 
inflammation  and  constitutional  reaction  are  great,  a moderate  general 
bleeding  may  become  necessary,  but  in  most  cases  cupping  or  leeching 
will  suffice. 

Cold  may  be  applied  to  tbe  joint  by  the  India-rubber  sack  already 
spoken  of,  which  will  enable  the  surgeon  to  obtain  a uniform  tempera- 
ture of  any  degree. 

A still  simpler  plan  is  to  immerse  , the  injured  part  in  a vessel  of 
water  of  the  desired  temperature.  For  instance,  if  it  is  the  ankle,  the 
pail  containing  the  water  must  be  placed  by  the  patient’s  bedside,  near 
enough  to  permit  his  heel  to  rest  upon  its  bottom,  a large  sponge  being 
interposed  to  prevent  hurtful  pressure ; the  thigh  may  be  supported 
by  pillows. 

Irrigation  by  means  of  the  apparatus  described  at  pages  87  and  91 
is  also  a good  plan  for  obtaining  the  sedative  influence  of  cold. 

In  slight  cases  of  sprains,  an  immersion  of  the  part  in  cool  water 
for  forty-eight  hours  will  often  relieve  the  pain  and  swelling  suffi- 
ciently to  enable  the  patient  to  dispense  with  it ; in  severer  cases,  to 
obtain  any  decided  result  an  immersion  of  eight  or  ten  days,  or  even 
longer,  will  be  necessary. 

Cloths  wrung  out  of  cold  water,  or  water  mixed  with  alcohol  and 
tincture  of  camphor,  wrapped  about  the  joints,  have  been  recommended 
as  a convenient  method ; but  the  proper  management  of  such  a dress- 
ing is  really  difficult,  for  without  the  most  assiduous  attention  on  tbe 
part  of  the  attendant  inequalities  of  the  temperature  of  the  parts  are 
sure  to  result  in  changing  the  cloths,  and  therefore  frequent  and  inju- 
rious reactions  must  occur. 

Cold  affusion,  by  directing  a stream  of  water  from  a pitcher  held 
five  or  six  feet  above  the  bed  upon  the  joint,  in  the  first  or  acute  stage 
of  a strain,  will  be  likely  to  do  more  harm  than  good  b}r  the  frequent 
reactions  thereby  produced;  but  whfen  the  inflammatory  symptoms 
have  been  controlled  by  appropriate  remedies,  cold  affusion  will  con- 
tribute greatly  to  bring  about  a rapid  convalescence. 

Should  cold  be  found  disagreeable  to  the  patient’s  feelings,  fomen- 
tations with  solutions  of  acetate  of  lead  and  opium,  hvdrochlorate  of 
ammonia  and  opium,  or  warm  salt  water,  may  be  substituted  for  it. 

Poultices  of  scraped  Irish  potatoes,  carrots,  or  hashed  persil  made 
with  lead  water,  are  the  favorite  remedies  of  some  practitioners. 


SPRAINS  OR  STRAINS. 


499 


While  the  acute  symptoms  are  passing  away,  the  parts  become 
discolored  and  pass  through  various  shades  of  green,  blue,  purple, 
and  yellow  to  the  normal  color  of  the  skin.  Any  remaining  stiffness, 
; weakness,  or  swelling  of  the  joints  must  be  treated  with  stimulating 
applications,  such  as  volatile  liniment,  Granville’s  lotion,  and  fish  brine, 
j Frictions  and  massage  will  likewise  contribute  to  their  removal. 

Paralysis  of  a limb  resulting  from  a sprain  will  be  benefited  by 
electricity,  galvanism,  the  counter -irritation  of  the  heated  hammer 
adverted  to  farther  on,  and  repeated  blistering. 

For  some  time  after  the  injury  it  will  be  advisable  to  support  the 
ijoint  by  elastic  bandages.  I sometimes  find  advantage  accruing  as 
regards  comfort  and  facility  in  walking  from  the  use  of 
the  apparatus  seen  in  Fig.  449.  It  consists  of  an  ordi- 
nary laced  boot  with  two  side  stems  attached  to  its  sole 
:and  running  up  the  limb  to  a point  just  below  the  knee, 
where  they  are  connected  together  by  a padded  me- 
tallic strip  which  embraces  this  part  of  the  leg ; a spiral 
spring  extends  between  one  of  the  side  rods  and  the  sole 
of  the  boot,  which  by  its  elasticity  brings  the  foot  in  a 
rectangular  position  again  after  it  has  been  extended  or 
'flexed. 

It  cannot  be  too  forcibly  impressed  upon  the  mind  of 
the  student  that  all  interference  with  the  knife,  with  a 
view  of  giving  pssue  to  the  effused  blood,  is  highly 
reprehensible ; as  such  incisions  cannot  accomplish  this 
object ; while,  on  the  other  hand,  they  would  be  likely 
to  cause  inflammation  of  the  cellular  tissue.  Nature 
amply  provides  for  the  removal  of  the  blood  in  due 
time  by  means  of  the  absorbents  everywhere  present; 
while,  it  may  be  remarked,  its  temporary  presence  in  the  tissues  will 
not  be  productive  of  any  harm. 

| Compression,  after  the  acute  symptoms  have  passed,  by  means  of  a 
proper  bandage,  will  exercise  a beneficial  influence  upon  sprained 
joints.  Baudens  has  recommended  one  for  the  ankle  which  is  exceed- 
ingly efficient  and  elegant.  It  is  applied  in  the  following  manner : 
first  pad  the  depressions  below  the  malleoli  with  cotton  or  tow,  and 
iver  this  lay  three  compresses,  imbricating  and  crossing  them  over 
phe  instep ; then  with  a roller  eight  yards  long  and  two  inches  wide 
nclose  the  ankle,  beginning  by  placing  its  initial  extremity  upon  the 
nner  surface  of  the  os  calcis  of  the  left  foot  (outer  side  for  the  right), 
is  low  down  upon  the  point  of  the  heel  as  possible,  carry  the  cylinder 
ffiliquely  across  the  dorsum  of  the  foot  to  the  root  of  the  little  toe, 
around  the  base  of  the  toes  to  gain  the  inner  border  of  the  foot,  then 
mossing  the  previous  turn  upon  its  dorsum  go  around  the  heel  to  the 
point  of  departure;  continue  these  turns  in  this  manner  until  the  foot 
tnd  ankle  are  neatly  covered  in.  The  bandage  being  completed,  apply 
)ver  its  surface,  with  a brush,  a solution  of  starch;  in  twenty-four 
aours  it  will  be  thoroughly  dry.  The  limb  should  be  kept  quiet  and 
n an  elevated  position  from  ten  to  thirty  days  according  to  the  severity 
pf  the  injury.  For  the  knee,  the  middle  part  of  the  spiral  bandage 


Fig.  449. 


Shoe  to  assist  in 
walking  after 
dislocation. 


500 


DISLOCATIONS  IN  GENERAL. 


described  at  page  209  will,  when  starched  in  the  same  way,  serve  a 
good  purpose  in  keeping  the  joint  immovable,  and  making  compression. 

Some  constitutional  treatment  will  be  necessary  in  those  persons 
who  are  of  a gouty  or  rheumatic  diathesis,  or  whose  general  health  is 
shattered  by  long  confinement ; the  appropriate  remedies  are  colchi- 
cum,  iron,  cod-liver  oil,  and  alteratives. 

Although  a slight  sprain  will  get  well  under  the  use  of  tincture  of 
arnica,  spirits  of  camphor,  or  a mixture  of  laudanum  and  lead-water 
applied  locally,  while  the  patient  is  pursuing  his  ordinary  occupation, 
yet  it  will  always  be  the  safest  and  surest  plan  to  enjoin  absolute  rest 
for  the  injured  limb  a few  days. 

W ith  the  starched  bandage  patients  can  take  exercise  upon  a crutch, 
which  will  contribute  greatly  in  maintaining  their  general  health  until 
the  parts  are  sufficiently  recovered  to  submit  to  passive  exercise,  and 
thus  gradually  resume  their  natural  functions. 

This  passive  exercise  should  not  be  delayed  too  long ; otherwise  the 
joint  may  become  irreparably  damaged  by  anchylosis. 


\ 


CHAPTER  II. 

DISLOCATIONS  IN  GENERAL. 

Nomenclature. — A dislocation  or  luxation  is  the  permanent  dis- 
placement of  joint-surfaces  from  their  normal  relations  with  each 
other. 

When  it  results  from  external  violence  or  muscular  action,  it  is 
called  a traumatic  dislocation. 

If  the  displacement  occurs  from  some  morbid  changes  in  the  joint 
itself,  as  ulceration  or  caries  of  its  articular  surfaces,  it  is  termed  a 
pathological  dislocation ; but,  even  in  this  case,  muscular  contraction  or 
some  slight  external  force  is  generally  the  immediate  cause. 

Congenital  dislocation  is  such  as  is  met  with  in  recently -born  infants, 
having  occurred  during  intra-uterine  life. 

A complete  dislocation  is  one  where  the  joint  surfaces  have  been 
completely  separated  from  each  other,  and  an  incomplete,  or  partial 
dislocation,  where  they  yet  remain  in  apposition  to  some  extent;  the 
latter  variety  occurring  mostly  in  ginglymoid  articulations. 

A single  dislocation,  as  its  name  implies,  affects  but  one  joint,  while 
in  a double  dislocation  two  corresponding  joints  upon  opposite  sides  of 
the  body  suffer. 

In  multiple  dislocation  two  or  more  luxations  occur,  not  thus  corres- 
ponding; for  instance,  those  of  the  ankle  and  wrist,  shoulder  and  hip. 

The  terms  recent  and  old  dislocations,  although  arbitrary,  and  of' 
little  value  as  mere  expressions  of  lapse  of  time  since  the  injury,  yet 
they  are  of  much  practical  importance  when  considered  as  indications 


FREQUENCY. 


501 


of  the  pathological  changes  that  always  follow  it,  and  upon  the  nature 
and  extent  of  which  the  ease  or  difficulty  of  reduction  depends. 

In  a primitive  dislocation  the  head  of  the  displaced  bone  remains  in 
the  original  situation  in  which  it  was  first  forced ; in  consecutive  dislo- 
cation it  abandons  this  position  and  seeks  another,  either  in  conse- 
quence of  some  peculiarity  in  the  application  of  the  violence,  or  from 
some  diseased  changes  in  the  bones  themselves. 

No  dislocation  can  occur  without  some  injury  to  the  surrounding 
soft  parts ; when  this  is  moderate,  or  about  the  average  amount,  the 
luxation  is  technically  said  to  be  simple,  while  the  term  complicated 
indicates  that  it  is  accompanied  with  an  unusual  amount  of  contusion 
of  the  surrounding  tissues,  tearing  of  ligamentous  and  muscular  fibres, 
rupture  of  some  bloodvessel  or  nerve,  or  with  a wound. 

A compound  dislocation  is  defined  to  be  one  where  there  is  a com- 
munication established  between  the  cavity  of  the  joint  and  the  exter- 
nal air. 

Malgaigne  proposes  the  adoption  of  the  term  complex  to  imply  that 
the  luxation  is  accompanied  with  articular  fracture. 

From  the  fact  that  all  authors  have  not  agreed  as  to  which  of  the 
two  bones  comprising  a joint  should  be  considered  as  the  displaced 
one,  more  or  less  confusion  has  arisen  in  consequence  in  designating 
the  varieties  of  dislocation ; and  it  was  not  until  recently  that  the 
rule  has  been  generally  adopted  to  regard,  in  dislocations  of  the  extre- 
mities, that  bone  displaced  which  is  farther  from  the  trunk ; and  in  dis- 
locations of  the  bones  of  the  trunk,  that  one  farthest  from  the  cranium. 
The  ankle-joint  is,  however,  excepted  from  the  rule  without  reason. 
The  arbitrary  use  of  such  terms  as  downwards,  upwards,  forwards,  back- 
wards, and  their  combinations  to  express  the  direction  of  a dislocated 
bone,  has  also  caused  more  or  less  perplexity ; and,  therefore,  recent 
writers  have  abandoned  them,  and  sought  others  more  exact;  so  that 
now  appellations,  based  upon  the  anatomical  relations  assumed  by  the 
head  of  the  luxated  bone,  are  coming  into  general  use ; for  instance, 
instead  of  following  Sir  A.  Cooper,  and  designating  the  four  principal 
dislocations  of  the  hip-joint  as  taking  place  upwards,  backwards,  for- 
wards, and  downwards,  surgeons  prefer  to  imitate  Malgaigne  and 
Nelaton,  and  adopt  the  anatomical  terms  iliac,  ischiatic,  ileo-pubic, 
and  ischio-pubic  to  express  them ; the  latter  is  certainly  the  prefera- 
ble method. 

Frequency. — All  the  joints  are  liable  to  dislocation,  but  not  in  the 
same  degree;  the  enarthrodial  articulations  suffer  more  frequently  than 
the  arthrodial,  ginglymoid,  and  the  amphi-arthrodial,  under  which  latter 
fall  the  hinge-like  joints,  and  those  characterized  by  gliding  movements 
of  the  bones  upon  one  another,  as  is  observed  in  the  carpus,  tarsus,  and 
the  junctions  between  the  vertebrae.  The  greater  range  of  motion  of  ^ 
the  enarthrodial  or  ball-and-socket  joints,  coupled  with  the  anatomical 
arrangement  of  their  constituents — a shallow  socket,  limited  contact 
between  their  opposing  bony  surfaces,  and  loose  capsular  ligament — - 
is  the  principal  cause  of  this  relative  greater  frequency.  For,  under 
these  conditions,  there  is  a much  greater  chance  of  a dislocation  upon 
the  application  of  external  force  than  where  the  joint  surfaces  are 


502 


DISLOCATIONS  IN  GENERAL. 


broad,  and  bound  together  by  strong  and  thick  bands  of  ligamentous 
fibres  which  limit  the  extent  of  joint  motion  to  the  simple  gliding  of 
the  bones  upon  each  other,  or  to  that  yet  more  extended  movement 
forwards  and  backwards  of  which  the  knee  is  the  most  perfect  type. 

Besides  these  circumstances,  the  position  of  the  bones  will  also  have 
an  important  influence;  as  those  most  exposed  will,  caeteris  paribus,  be 
more  liable  to  dislocation  than  the  bones  deeply  seated  or  well  pro- 
tected with  soft  parts. 

The  operation  of  these  influences  is  strikingly  seen  by  reference  to 
the  following  table  of  488  cases,  drawn  up  by  Malgaigne: — 


Dislocation  of  the  shoulder  . 

. 321 

Dislocation  of  the  fingers 

. . 7 

“ “ hip  . 

. 34 

“ “ jaw 

. . 7 

“ “ clavicle  . 

. 33 

“ “ knee  . 

. . 7 

“ “ elbow 

. 2(1 

“ “ patella 

. 2 

“ “ foot  . 

. 20 

“ “ spine  . 

. 1 

“ “ thumb 

. 17 

— 

“ “ wrist 

. 13 

Total 

. 488 

The  comparative  frequency  of  dislocation  in  the  upper  and  lower 
extremities  is  in  the  ratio  of  seven  to  one.  The  facility  with  which 
the  epiphyses  separate  from  the  shafts  of  long  bones  in  youth,  and 
the  brittleness  of  the  bones  in  the  aged,  render  these  two  classes  of 
persons  more  liable  to  fracture  than  to  dislocation,  which  last  is  most 
frequently  encountered  among  persons  between  thirty  and  sixty-five 
years  of  age. 

Causes. — The  causes  of  dislocation  are  predisposing  and  exciting; 
among  the  former  may  be  ranked  age,  sex,  the  state  of  the  general 
health,  and  the  position  of  the  joint  surfaces  at  the  time  of  the  inflic- 
tion of  the  injury. 

As  has  already  been  stated,  it  is  rare  in  childhood  and  old  age,  on 
account  of  the  condition  of  the  bones  at  these  periods  favoring  fracture 
rather  than  dislocation. 

According  to  the  interesting  statistics  of  Malgaigne,  males  are  more 
frequently  affected  than  females  in  the  proportion  of  seven  to  one; 
this  is  probably  owing,  in  a great  measure,  to  the  less  exposure  of 
females  to  mechanical  violence  in  their  daily  avocations  of  life. 

Persons  of  relaxed  habit  of  body,  in  general  bad  health,  and  who 
have  suffered  from  rheumatism,  gout,  and  syphilis,  are  liable  to  have 
their  joints  dislocated  by  a force  which,  were  they  in  health,  would 
not  produce  any  permanent  displacement. 

Great  relaxation  of  the  ligaments,  or  a large  collection  of  synovia 
in  a joint,  may  permit  a complete  dislocation  without  any  rupture  of 
the  tissues  in  its  neighborhood,  or  will  even  enable  the  person  to  effect 
it  at  his  pleasure. 

Dr.  Haynes,  of  Saratoga,  New  York,  has  reported  a case  of  the 
kind  in  which  a lad  aged  seven  years  was  able  to  dislocate  and  reduce 
at  will  the  knee,  elbow,  wrist,  thumb,  and  fingers. 

Sir  A.  Cooper  relates  three  other  instances : one  of  a dancing-girl 
who  could  throw  the  patella  upon  the  outer  condyle  of  the  femur,  and 
in  whom  this  had  occurred  when  a child  from  violent  exertion;  the 
second  case  was  that  of  a lad  who  had  been  punished  on  board  ship 


PATHOLOGICAL  ANATOMY. 


503 


by  having  his  arm  elevated  and  tied  above  his  head  while  he  stood 
upon  a small  projection  upon  the  deck;  he  could  dislocate  the  shoul- 
der by  merely  elevating  the  arm  to  the  head ; the  last  case  occurred 
in  a man  fifty  years  old,  who  had  had  his  hip  dislocated,  and  was  ever 
after  that  able  to  cause  it  to  happen  whenever  he  chose. 

The  position  of  the  articulating  surfaces  at  the  time  of  the  applica- 
tion of  the  force  will  also  have  an  important  influence,  inasmuch  as  in 
certain  postures  of  the  limbs  the  articular  surfaces  will  not  be  in  such 
close  and  extended  contact  as  in  others;  as,  for  instance,  when  the 
arm  is  abducted  and  elevated,  the  thigh  flexed  upon  the  body,  the 
lower  jaw  depressed;  or  lastly,  when  a limb  is  in  a restrained  or 
twisted  position.  All  of  these  circumstances  will  materially  favor  the 
production  of  a dislocation. 

The  exciting  or  efficient  causes  are  external  violence  and  muscular 
action.  The  former  acts  either  directly  upon  the  joint,  or  indirectly 
upon  it  through  the  limb  below,  the  latter  mode  being  the  most  fre- 
quent in  causing  dislocation.  We  see  the  influence  of  indirect  vio- 
lence exemplified  in  these  cases  of  luxation  of  the  hip  and  shoulder 
produced  by  falls  from  a height  upon  the  feet  and  hands.  If,  instead 
of  alighting  upon  the  feet  and  hands,  the  knees  and  elbows  come  first 
in  contact  with  the  ground,  the  force  acts  in  a much  more  efficient 
manner,  for  the  reason  that  the  thigh  and  arm,  being  inflexible  levers, 
transmit  it  undecompounded  and  undiminished  to  the  joint  above. 
The  bending  of  a limb  at  an  intervening  articulation  during  the  appli- 
cation of  violence,  will  often  prevent  the  occurrence  of  a dislocation. 

Mere  muscular  action  will  sometimes  effect  a dislocation  without 
the  aid  of  external  violence,  and  is  due,  in  a great  measure,  to  some 
accidental  position  assumed  by  a limb,  destroying  for  the  time  the 
antagonism  of  the  muscles  inserted  into  the  bone,  one  set  of  which 
thus  acting  more  energetically  than  the  opposing  set,  will  drag  the 
head  of  the  bone  from  its  socket  into  an  abnormal  position.  Disloca- 
tion from  muscular  action  has  been  observed  most  frequently  in  the 
temporo-maxillary  and  scapulo-humeral  articulations,  though  cases 
are  recorded  in  which  the  hip  and  patella  have  been  luxated  from  the 
same  cause. 

Organic  disease  of  the  cartilages  and  ligaments  from  ulceration  and 
caries  will  favor  the  occurrence  of  dislocation  from  muscular  action. 

Pathological  Anatomy.— The  pathological  changes  consecutive 
on  dislocation  are  exceedingly  interesting  and  important,  and  ought 
to  be  carefully  studied  by  every  person  liable  to  be  called  upon  to 
reduce  a luxation,  as  it  is  upon  the  extent  of  these  that  the  practica- 
bility of  restoring  the  displaced  bone  depends  after  the  lapse  of  some 
time.  When  a recent  luxation  is  examined,  the  head  of  the  bone  will 
be  found  removed  from  its  socket  to  a greater  or  less  distance,  accord- 
ing to  the  nature  and  degree  of  the  violence  that  caused  the  displace- 
ment, and  the  character  of  the  tissues  surrounding  the  joint. 

The  ligaments  will  be  ruptured  in  various  degrees,  from  a mere  slit 
just  large  enough  to  permit  the  head  of  the  bone  to  escape  from  its 
capsule,  to  a complete  laceration  and  separation,  so  that  the  shreds 
and  remnants  hang  from  the  margins  of  the  joint,  or  in  front  of  its 


504 


DISLOCATIONS  IN  GENERAL. 


socket,  in  such  a manner  as  to  interpose  themselves  between  it  and 
the  head  of  the  bone;  the  cartilages  may  be  fissured,  or  even  torn 
from  the  bone;  and  in  complicated  cases  the  nerves  and  bloodvessels 
sometimes  participate,  and  are  violently  stretched  or  even  lacerated, 
producing  in  the  first  instance  paralysis  of  the  limb  below  the  dislo- 
cated joint,  and  in  the  other,  hemorrhage  into  the  socket  and  sur- 
rounding tissues. 

The  muscles  about  the  injured  articulation  are  usually  more  or  less 
violently  extended,  contused,  and  the  fibres  sometimes  torn  through; 
generally  tensely  stretched  upon  one  side  of  the  joint,  and  relaxed 
upon  the  other. 

Bones  are,  in  general,  more  disposed  to  be  luxated  in  certain  direc- 
tions than  in  others,  according  to  the  anatomical  arrangement  of  the 
joints ; thus  the  bones  of  the  forearm  at  the  elbow  are  more  com- 
monly displaced  backwards,  next  laterally,  and  rarely  forwards  from 
the  opposition  offered  by  the  olecranon  hooking  around  the  humeral 
condyles. 

According  to  Malgaigne,  the  direction  of  the  displacement  is  deter- 
mined by  the  point  and  extent  of  the  tearing  of  the  capsular  ligament. 

When  the  bones  are  promptly  restored  to  their  natural  relation  at 
the  joint,  the  functions  of  the  limb  will  be  again  established,  and  the 
injury  to  the  soft  tissues  repaired  more  or  less  perfectly,  according  to 
the  amount  and  nature  of  the  injury. 

If  this  restoration  is  not  accomplished  within  a few  weeks,  the 
inflammation  which  has  begun  in  the  parts  will  be  attended  with  the 
effusion  of  plastic  lymph  about  the  joint,  which  will  mat  and  glue  the 
adjacent  tissues  into  one  mass;  and  in  the  progress  of  the  case  the 
cellular  tissue  becomes  dense  and  thick,  the  neighboring  muscles 
undergo  fatty  degeneration ; the  head  of  the  bone,  reposing  upon  some 
muscle,  tendon,  or  bone,  contracts  new  and  intimate  relations  with 
them  by  the  formation  of  a new  socket  and  capsular  ligament,  com- 
municating or  not  with  the  old  capsule,  according  as  its  rupture  was 
originally  complete  or  not.  An  imperfectly  organized  synovial  mem- 
brane will  also  be  formed  upon  the  inner  surface  of  the  new  joint. 
The  old  socket  participates  in  these  changes,  and  is  gradually  effaced 
by  its  margins  being  levelled  with  the  adjoining  surface. 

Symptoms. — The  symptoms  of  dislocation  are,  pain,  alteration  in  the 
figure  of  the  joint,  deviation  of  the  axis  of  the  limb  from  a right  line, 
and  an  alteration  in  its  length ; contusion  and  ecchymosis,  immobility 
and  absence  of  crepitus. 

At  the  moment  of  the  infliction  of  the  injury  the  patient  may  be 
conscious  of  something  having  given  way  or  altered  its  position  in  a 
joint,  described  by  some  as  a “crack”  or  “noise;”  pain  is  felt  in  the 
part,  which  varies  in  its  intensity  and  character,  but  is  generally  severe 
(nervous  and  irritable  persons  suffering  the  most),  and  lasts  for  a few 
days  or  even  weeks.  It  is  caused  by  the  stretching  and  rupture  of 
the  nervous  filaments  about  the  joint,  and  is  aggravated  by  handling 
the  limb,  and  also  when  inflammatory  action  supervenes.  Should  the 
principal  nerve  be  pressed  upon  by  the  displaced  bone,  the  extremity 
will  tingle  and  feel  numb. 


SYMPTOMS. 


505 


The  alteration  in  the  normal  contour  of  the  joints  is  an  important 
character  in  the  symptomatology  of  dislocation.  It  is  due  to  two 
causes : first,  to  the  changed  position  of  the  extremities  of  the  bones 
entering  into  their  composition ; second,  to  effusion  of  blood  from  the 
ruptured  vessels,  and  inflammatory  exudations. 

From  these  two  causes  will  proceed  those  alterations  in  the  normal 
positions  and  relations  of  the  bony  prominences  and  depressions  which 
• are  naturally  present  and  recognizable  about  the  joints  in  their  healthy 
state. 

If  the  swelling  results  from  effused  blood,  it  will  occur  immediately 
after  the  injury,  while  that  from  inflammatory  action  will  appear,  pan" 
passu,  with  the  increase  of  the  inflammation. 

An  alteration  in  the  axis  of  the  limb  will  be  observed,  which,  in- 
. stead  of  representing  a straight  line,  will  be  broken  into  two  sections, 
placed  at  a greater  or  less  angle  with  each  other,  according  to  the 
inclination  of  the  displaced  bone  with  that  bone  to  which  it  is  nor- 
mally connected. 

The  limb  will  also  generally  be  found  more  or  less  forcibly  rotated 
inwards  or  outwards,  and  sometimes  stands  off  from  the  body  at  an 
angle. 

A dislocated  limb  will  commonly  undergo  some  change  in  its 
length ; though  in  the  ginglymoid  joints,  where  from  the  breadth  of 
the  articular  surfaces  a partial  displacement  only  most  always  occurs, 
no  change  of  length  will  be  observed.  In  most  of  the  other  joints 
some  shortening  takes  place ; yet  there  are  some  exceptions,  the  most 
notable  of  which  are  dislocation  of  the  humerus  downwards,  and  of 
the  femur  into  the  thyroid  foramen  ; in  both  of  these  cases  the  limb 
will  be  lengthened  half  an  inch  or  more. 

Contusions  and  ecchymoses  about  the  injured  joint  or  elsewhere 
should  not  be  forgotten  or  overlooked  when  considering  the  nature  of 
this  injury,  and  particularly  the  modus  operandi  of  the  force  produc- 
ing it. 

Immobility  is  one  of  the  most  valuable  symptoms  of  dislocations 
from  the  fact  that  the  joints  have  an  important  agency  in  the  functions 
of  the  limbs,  so  that  any  displacement  of  their  constituent  elements 
will  bring  about  a speedy  abolition  of  motion.  This  is  seen  in  dislo- 
cation of  the  shoulder  and  hip  where  the  patient  cannot  voluntarily 
move  the  affected  arm  or  walk  upon  the  leg  without  excruciating  pain. 
These  restrained  motions  will  also  be  manifest  when  the  surgeon 
manipulates  with  the  limb,  which  always  causes  acute  pain. 

AVhen  the  ligaments  are  thoroughly  lacerated,  there  may  be  in  the 
beginning,  before  the  muscles  are  spasmodically  contracted,  preter- 
natural motion,  so  that  a fracture  might  be  suspected  where  it  really 
does  not  exist. 

Immobility  is  due  to  several  causes ; the  principal  of  which  are 
muscular  contraction,  interlocking  of  the  head  of  the  displaced  bone, 
as  sometimes  happens  in  dislocation  of  the  elbow,  the  presence  of  some 
osseous  prominence  as  seen  in  the  hip,  in  which  the  projecting  lip  of 
the  acetabulum  will  frequently  oppose  itself  to  any  movement  of  the 
head  of  the  femur,  and  lastly,  ligamentous  bands  will  cause  it.  It  will 


506 


DISLOCATIONS  IN  GENERAL. 


generally  be  found,  however,  that  two  or  more  of  these  causes  will  he 
in  operation  in  the  same  case  at  the  same  time. 

Crepitus  is  another  symptom  sometimes  connected  with  dislocation, 
and  results  probably  from  the  rubbing  together  of  surfaces  roughened 
by  effused  lymph.  It  is  never  observed  until  after  the  inflammatory 
process  has  been  established ; which  fact  gives  strong  support  to  the 
above  explanation.  Malgaigne  attributes  the  crepitus  to  the  rubbing 
of  the  head  of  the  displaced  bone  against  a bony  surface  denuded  of 
its  periosteum.  However,  the  subdued  dull  sound  produced  by  the 
rubbing  together  of  roughened  cartilages  or  synovial  membranes  is 
quite  distinct  from  the  sharp,  quick,  and  dry  sound  proceeding  from 
the  friction  of  the  extremities  of  a broken  bone ; and  which,  although 
not  present  in  all  cases  of  fracture,  will  yet  be  observed,  wrhen  it  is 
present,  from  the  first  moment  of  the  injury.  Lastly,  if  the  surgeon 
seizes  the  dislocated  joint  in  both  his  hands,  when  there  is  no  great 
swelling,  and  directs  an  assistant  to  move  the  limb  cautiously,  he  can 
generally  recognize  the  head  of  the  bone  in  its  new  position. 

Diagnosis. — It  should  always  be  borne  in  mind  that  although  in 
general  a dislocation  may  be  accurately  diagnosed  from  those  injuries 
and  diseases  which  resemble  it  in  their  symptoms,  yet  there  have  been 
cases  that  have  defied  the  skill  of  the  most  accomplished  surgeons. 

In  their  early  stages,  dislocations  may  be  confounded  with  fractures 
near  the  joints,  sprains  and  contusions;  and  in  their  later,  or  when 
the  bone  has  remained  unreduced  for  a long  period,  they  have  been 
simulated  by  anchylosis,  white  swelling,  deformed  callus,  and  exostosis. 
By  a close  attention  to  the  symptoms  we  have  already  laid  down,  a 
dislocation,  when  seen  early,  may  always  be  recognized.  If  the  joint 
is  much  swollen  and  the  bony  prominences  cannot  be  felt,  accurate 
measurements  of  the  limb  should  be  made  with  a tape-measure,  and 
comparisons  made  with  the  healthy  limb.  A knowledge  of  the  manner 
in  which  the  injury  was  produced  may  also  throw  some  light  on  the 
diagnosis.  The  limb  should  be  manipulated  to  ascertain  the  nature 
and  extent  of  the  movements  possessed  by  it.  M.  Malgaigne  recom- 
mends the  use  of  a slim  needle,  which  should  be  thrust  through  the 
tissues  down  to  the  bony  surfaces,  to  ascertain  with  precision  the  rela- 
tions of  the  prominences  and  depressions  of  the  latter. 

Prognosis. — In  simple  dislocation,  when  the  head  of  the  bone  is 
promptly  returned  to  its  socket,  and  no  great  injury  has  been  inflicted 
upon  the  limb,  the  joint  is  usually  speedily  restored  to  its  normal 
integrity  in  between  three  and  five  weeks;  so  that  the  patient  can  use 
the  limb  without  pain  or  inconvenience,  although  some  disposition  to 
subsequent  displacement  may  yet  remain. 

Compound  and  complicated  dislocations  are  more  serious,  both  as 
regards  danger,  to  life  and  the  ultimate  usefulness  of  the  limb.  They 
usually  result  from  a greater  amount  of  violence  than  simple  disloca- 
tion, and  are  hence  dangerous  in  proportion  to  its  amount,  to  the 
extent  of  the  injury,  and  the  importance  of  the  parts  damaged. 

The  joints  are  more  frequently  left  in  a weakened  and  altered  con- 
dition, disposing  them  both  to  a recurrence  of  the  dislocation  and  to 
subsequent  inflammatory  and  ulcerative  changes,  which  sometimes 
require  amputation  ultimately,  to  save  the  patient's  life. 


TREATMENT. 


507 


Treatment. — The  treatment  of  dislocations  presents  four  indica- 
tions : 1st,  to  restore  the  bone  to  its  normal  position ; 2d,  to  facilitate 
the  restoration  of  the  damaged  parts ; 3d,  to  re-establish  the  natural 
motions  of  the  articulations ; 4th,  to  combat  any  complications  that 
may  occur. 

1.  To  restore  the  hone  to  its  normal  position. — There  are  two  methods 
'by  which  this  may  be  accomplished:  first,  by  manipulations;  and 
second,  by  making  extension  and  counter-extension. 

The  first  plan,  or  that  by  manipulation,  consists  in  changing  the 
position  of  the  displaced  bone  in  such  a manner,  by  the  hands  of  the 
surgeon,  that  those  muscles  which  oppose  the  reduction  are  relaxed, 
while  its  head  is  thrown,  by  making  a lever  of  the  bone,  near  the 
socket,  when  the  contraction  of  the  muscles  themselves  will  draw  it 
with  a “snap”  into  its  natural  position,  and  the  reduction  is  accom- 
plished. The  details  of  the  process,  as  applicable  to  individual  disloca- 
tions, will  be  discussed  under  appropriate  headings.  Simple  pressure 
with  the  fingers  will  often  succeed  in  replacing  the  bones  when  only 
partially  luxated. 

The  second  process,  or  that  by  extension  and  counter-extension,  is 
effected  by  the  natural  forces  of  the  surgeon,  aided  by  assistants  if 
additional  power  is  requisite,  or  by  the  application  of  certain  mecha- 
nical appliances.  The  extension  should  be  gradually  made,  with  the 
least  possible  pain  and  inconvenience  to  the  patient;  the  part  to  which 
the  extending  lac  is  applied  must  be  protected  by  being  covered  with 
a wet  roller,  to  protect  the  skin  and  prevent  its  slipping.  In  putting 
on  this  roller,  the  integuments  may  be  drawn  up  a little,  so  that  the 
traction  will  not  stretch  the  skin  painfully  before  the  extending  force 
is  brought  to  bear  upon  the  parts  beneath. 


Fig.  450. 


A secure  way  of  fastening  the  extending  lac 
over  the  wet  roller  is  with  the  clove-hitch ; 
its  two  ends  are  then  knotted  so  as  to  form  a 
loop,  which  affords  the  surgeon  a good  pur- 
chase if  he  wishes  to  use  his  hands;  or  it  may 
be  placed  over  the  hooks  of  the  pulleys. 

Any  amount  of  power  can  be  obtained  with 
the  pulleys  (Fig.  452);  but  they  are  not  now 


Fig.  451. 


Application  of  the  clove-hitch. 


508 


DISLOCATIONS  IN  GENERAL. 


much  employed  since  the  introduction  of  the  anaesthetics,  which  so 
thoroughly  relax  the  muscles  that  with  the  hands  alone  almost  all  recent 
cases  of  dislocation  may  be  promptly  reduced.  If  it  is  necessary, 
however,  to  have  recourse  to  them,  the  patient  should  be  placed  in  a 
recumbent  posture,  or  permitted  to  sit  up,  as  found  most  convenient, 
and  the  extending  lac  applied  as  we  have  above  described;  or  a broad 
leather  belt  with  a loop  attached  may  be  buckled  around  the  limb,  to 
which  one  of  the  hooks  of  the  pulleys  is  fastened,  the  other'  hook 


Fig.  452. 


being  placed  in  the  iron  ring  screwed  into  the  wall.  The  counter- 
extending  band,  formed  of  a sheet  or  a broad  piece  of  strong  muslin, 
is  arranged  in  an  opposite  direction  to  the  pulleys,  and  its  two  ends 
secured  to  a point  in  the  wall  or  floor  in  the  line  of  the  direction  of 


Fig.  453. 


traction.  Fig.  287  illustrates  the  mode  of  reducing  dislocation  of  the 
hip  by  the  pulleys. 

Dr.  Fanestock,  of  Pittsburg,  Pa.,  instead  of  the  pulleys  has  recom- 
mended as  a good  substitute  the  rope  windlass,  which  is  thus  described 
by  Dr.  Gilbert:  “Place  the  patient,  and  adjust  the  extending  and 
counter-extending  bands  as  for  the  pulleys;  then  procure  an  ordinary 
bed-cord,  or  a wash-line,  tie  the  ends  together  and  again  double  it 
upon  itself,  pass  it  through  the  extending  tapes  or  towels,  doubling 


TREATMENT. 


509 


the  whole  once  more,  and  fasten  the  distal  end,  consisting  of  four  loops 
of  a rope,  to  a window-sill,  door-sill,  or  staple,  so  that  the  cords  are 
drawn  moderately  tight ; finally,  pass  a stick  through  the  centre  of  the 
double  rope,  then,  by  revolving  the  stick  as  an  axis,  or  double  lever, 


Fig.  454. 


Application  of  the  rope  windlass. 


the  power  is  produced  pre- 
cisely as  it  should  be  in  such 
cases,  viz.,  slowly,  steadily, 
and  continuously.” 

The  same  steady  and  con- 
tinuous power  may  also  be 
obtained  by  another  simple 
contrivance,  the  dislocation 
tourniquet  of  Mr.  Bloxham, 
of  London.  This  instrument 
resembles  the  ordinary  tour- 
niquet of  Petit,  and  acts  in  a 
similar  manner ; by  turning 
the  screw  the  extending  cord, 
which  is  fixed  between  the 
band  encircling  the  limb  and 
a staple  in  the  wall,  is  gra- 
dually shortened  by  almost 
imperceptible  increments  of 
power  until  the  bone  is  drawn 
into  its  natural  position. 

Mayor,  Sedillot,  and  other 
European  surgeons  have  de- 
vised special  instruments  for 
j the  purpose  of  making  exten- 
sion; but  those  already  de- 
j scribed  will  answer  every  pur- 
pose as  well  as  the  most  com- 
plex machines. 


Fig.  455. 


Bloxham’s  dislocation  tourniquet. 


510 


DISLOCATIONS  IN  GENERAL. 


The  surgical  adjuster  of  Dr.  Jarvis  is  also  a powerful  instrument, 
and  has  been  employed  by  its  inventor  successfully  in  many  cases  of 
old  luxations. 

Another  mode  of  applying  power  to  a dislocated  limb  is  by  con- 
tinuous elastic  extension,  which  is  certainly  destined  in  future  to  play 
an  important  role  in  the  treatment  of  this  class  of  injuries,  especially 
in  “ old”  and  congenital  luxations.  As  my  experience  in  its  use  has 
been  limited  to  two  cases  of  old  dislocation,  I am  at  present  illy  pre- 
pared to  decide  upon  its  merits  from  personal  observation,  yet  a con- 
sideration of  its  mode  of  action,  and  a knowledge  of  its  effects  in  other 
surgical  injuries,  in  which  the  contraction  of  the  muscles  pla}rs  an 
important  agency,  induce  me  unhesitatingly  to  accept  the  present 
success  of  elastic  extension  in  the  reduction  of  old  and  congenital 
dislocations  as  a harbinger  of  more  brilliant  triumphs  in  this  field  of 
surgical  therapeutics. 

Much  credit  is  due  to  Dr.  Henry  G.  Davis,  of  New  York,  for  the 
development  of  this  important  principle.  He  remarks,  “ that  by  this 
plan  of  elongating  the  soft  tissues,  all  dislocations,  whether  recent  or  of 
many  years'  standing;  all  fractures,  all  deformities  that  are  dependent 
upon  the  soft  tissues  are  entirely  within  our  control.  These  soft  tis- 
sues can  be  elongated  or  shortened  as  we  please.  Ligaments  that  are 
inextensible,  that  are  designedly  made  unyielding,  are  no  exception  to 

this  rule We  have  reduced  dislocated  hips  at  all  periods  of 

time,  from  the  recent  up  to  that  of  fourteen  years’  standing,  and,  in 
the  latter  case,  restored  a club-foot  on  the  same  limb  at  the  same  time. 

“So  far  as  the  certainty  of  a reduction  is  affected,  a luxation  of 
twenty  years’  standing  is  upon  the  same  footing  as  one  of  twenty  days. 
The  principal  difference  is  in  the  length  of  time  required  to  accom- 
plish it.  We  do  not  say  there  is  the  same  certainty  of  the  joints  being 
equally  useful  in  both  cases,  only  that  each  can  with  certainty  be  re- 
stored to  its  original  locality. 

“All  danger  of  injury  to  the  bloodvessels  or  nerves  by  this  mode 
of  preparing  the  parts  will  be  avoided,  as  they  elongate  with  the  other 
soft  tissues.  This  is  of  the  highest  importance ; for  it  is  well  known 
that  in  old  dislocations  of  the  humerus  attempts  at  reduction  have  in 
some  instances  been  most  disastrous.” 

The  mode  of  applying  the  elastic  cords  will,  of  course,  vary  with 
the  position  of  injured  joints;  the  general  plan  being  to  apply  adhe- 
sive strips  to  the  limb  below,  to  which  the  elastic  cords  may  be 
attached,  the  balance  of  the  arrangement  will  readily  suggest  itself  to 
the  surgeon  as  the  requirements  of  the  various  cases  are  presented  to 
his  mind. 

2.  For  fulfilling  the  second  indication,  that  is,  to  facilitate  the  restora- 
tion of  the  damaged  tissues. — The  joint  should  be  kept  quiet,  and  in 
such  a position  that  the  dislocation  is  not  likely  to  recur ; during 
the  time  that  the  torn  ligaments  are  healing  a suitable  amount  of  sup- 
port must  be  given  to  the  joint. 

3.  The  third  indication,  to  re-establish  the  natural  motions  of  the  arti- 
culation, demands  that,  as  soon  as  the  inflammatory  symptoms  have 
abated,  passive  motion  must  be  had  recourse  to,  and  persevered  in 


DISLOCATION'S  OF  THE  HEAD  AND  TRUNK. 


511 


daily  until  the  functions  of  the  joint  are  restored ; which  will  seldom 
occur  inside  of  several  months. 

Absorption  of  the  effused  fluids  will  be  materially  hastened  by  in- 
frictions of  volatile  or  other  stimulating  liniments,  the  cold  douche, 
friction,  and  the  massage. 

4.  The  fourth  indication,  to  combat  any  complications  that  may  occur, 
requires  the  employment  of  antiphlogistics,  general  and  local,  to  con- 
trol the  inflammation,  which  is  developed  in  the  joint  in  almost  all 
cases. 

The  best  local  applications  are  evaporating  lotions  of  alcohol  and 
water,  and  solution  of  acetate  of  lead,  with  the  tincture  of  opium. 

If  the  case  should  be  complicated,  with  the  laceration  of  a nerve,  or 
an  artery  (in  the  latter  instance  giving  rise  to  aneurism)  the  bone 
should  be  reduced  in  the  usual  manner,  and  the  injured  nerve  and 
aneurism  subsequently  treated  as  though  they  were  primary  affections. 


CHAPTER  III. 

PARTICULAR  DISLOCATIONS. 

SECTION  I. 

DISLOCATIONS  OF  THE  HEAD  AND  TRUNK. 

Dislocation  of  the  Inferior  Manilla.  — Dislocation  of  the 
inferior  maxilla  takes  place  in  two  modes : First,  both  condyles  are 
displaced  from  the  glenoid  fossae  — bilateral  or  double  dislocation; 
second,  one  condyle  only  is  so 
displaced  — unilateral  or  single 
dislocation. 

The  former  variety  occurs  most 
frequently  in  the  proportion  of 
three  to  one. 

An  outward  displafcfement  of 
one  of  the  condyles  has  been 
observed;  but  this  can  only  hap- 
pen when  accompanied  with  a 
'fracture  upon  the  opposite  side. 

Dislocation  of  the  lower  jaw  is 
always  complete;  those  cases  de- 
scribed as  subluxations  appear 
to  be  nothing  more  than  the 
catching  of  the  head  of  the  coro- 
noid  process  against  the  anterior  border  of  the  inter-articular  cartilage. 

Causes. — It  arises  from  two  sources,  viz.,  muscular  action  and  ex- 
ternal force,  the  former  being  much  more  frequent  than  the  latter. 


Fig.  456. 


512 


PARTICULAR  DISLOCATIONS. 


According  to  Malgaigne,  of  40  cases  of  this  injury  25  resulted  from 
muscular  action,  viz.,  from  gaping,  15 ; from  convulsions,  5 ; from 
vomiting,  4;  from  rage,  1;  and  15  from  external  causes,  viz.,  from 
extracting  teeth,  9 ; from  thrusting  large  objects  into  the  mouth  forci- 
bly, 6.  Berard  saw  a case  of  unilateral  displacement  resulting  from 
force  applied  at  the  left  angle  of  the  jaw  from  behind  forwards.  He 
thinks  it  probable  that  the  chin  may  have  been  depressed  to  some 
extent  at  the  time  of  the  reception  of  the  injury.  Cases  are  also 
reported  where  the  dislocation  resulted  from  excessive  salivation  and 
violent  gesticulation. 

In  the  majority  of  cases  dislocation  happens  in  adults  between 
the  ages  of  twenty  and  thirty  years,  though  Malgaigne  and  Nelaton 
have  observed  it  in  an  aged  subject,  and  in  one  but  five  years  of  age. 

This  peculiar  exemption  in  infancy  and  in  old  age  is  ascribed  by 
Nelaton,  who  has  made  special  researches  into  this  subject,  to  the  fact 
that  at  the  former  period  of  life  the  coronoid  apophysis  is  too  short, 
and  in  the  latter  too  much  inclined  backwards  for  it  to  reach  the 
position  it  alw;ays  assumes  in  dislocation,  that  is,  against  the  inferior 
angle  of  the  malar  bone  outside  of  the  tubercle  formed  by  its  junction 
with  the  superior  maxillary. 

In  order  to  understand  the  mechanism  of  the  dislocation,  it  will  be 
well  to  remember  that  the  temporo-maxillary  articulation  is  provided 
with  a capsular  ligament  divided  into  two  cavities  by  an  inter-articular 
cartilage,  each  lined  by  its  own  proper  serous  membrane;  the  ex- 
ternal lateral  ligament  passes  from  the  tubercle  of  the  zygoma  to  the 
external  surface  of  the  neck  of  the  lower  jaw;  the  internal  extends 
between  the  spinous  process  of  the  sphenoid  bone  to  the  margins  of 
the  dental  foramen ; and  therefore  has  no  connection  with  the  joint. 
The  masseter,  temporalis,  and  internal  pterygoid  muscles  draw  the 
lower  ja^v  upwards  and  forwards  against  the  upper;  the  genio-glossus. 
genio-hyo  glossus,  mylo-hyoid,  and  digastricus,  depress  the  chin,  while 
the  external  pterygoid  and  a few  fibres  of  the  masseter  muscle  bring 
it  forwards.  This  anatomical  arrangement  will  permit  the  condyles 
to  slip  forwards  upon  the  transverse  apophysis  of  the  temporal  bone 
when  the  mouth  is  widely  opened,  and  to  regain  their  position  in  the 
glenoid  fossae  when  it  is  shut.  Now  if  when  it  is  in  the  former 
position  the  chin  be  still  further  depressed  by  muscular  action,  the 
condyles  will  be  displaced  forwards  by  the  combined  efforts  of  the 
external  pterygoid  and  a few  of  the  fibres  of  the  masseter.  Instead 
of  the  muscular  action,  if  a violent  blow  be  inflicted  upon  the  chin 
which  forcibly  depresses  it,  the  necks  of  the  condyles  will  be  brought 
more  in  a parallel  line  with  the  direction  in  which  the  fibres  of  the 
internal  pterygoid  and  the  masseter  act ; then,  instead  of  elevating  the 
jaw  by  making  a fulcrum  of  the  condyles  at  the  glenoid  cavities, 
which  always  happens  when  the  necks  of  the  condyles  are  in  an 
oblique  position  to  these  fibres,  these  muscles  will  draw  the  condyles 
into  an  abnormal  position  forwards. 

The  mechanism  of  unilateral  dislocation  is  the  same ; the  condyle 
which  is  not  displaced  will  be  rotated  in  the  glenoid  cavity,  while  the 


DISLOCATION'S  OF  THE  HEAD  AND  TRUNK. 


513 


Dislocation  of  inferior  maxilla. 


opposite  one  will  take  its  ordinary  Fi§-  457- 

position. 

Symptoms. — The  symptoms  in  re- 
cent cases  of  dislocation  of  the  infe- 
rior maxilla  are  quite  characteristic. 

(Fig.  457.)  The  chin  is  depressed  and 
prominent,  the  mouth  widely  opened, 
the  lower  teeth  project  beyond  the 
upper,  so  that  the  whole  expression 
of  the  face  is  repulsive ; the  saliva 
drips  from  the  mouth,  and  articula- 
tion and  deglutition  are  impossible, 
or  performed  with  difficulty  and  pain. 

The  jaw  is  immovable  and  painful 
from  the  pressure  upon  the  temporal 
nerves ; the  temples  and  cheeks  are 
flattened  and  apparently  elongated  ; 
there  is  a prominence  over  the  con- 
dyles, and  between  them  and  the 
meatus  a depression  with  the  skin 
tensely  stretched  across  it. 

In  rare  cases  the  symptoms  are  not  so  prominent,  and  one  is  related 
in  which  the  injury  was  not  discovered,  and  the  jaw  remained  perma- 
nently unreduced.  In  an  instance  of  this  kind,  the  jaws  gradually 
approximate  each  other  so  that  the  patient  can  masticate  his  food, 
and  articulate  with  little  difficulty;  the  saliva  will  cease  to  escape 
from  the  mouth,  while  the  face  will  assume  a tolerable  appearance, 
although  the  chin  will  ever  remain  a little  advanced. 

In  unilateral  luxation  the  chin  will  be  generally  found  turned  to 
the  side  opposite  that  on  which  the  condyle  is  displaced ; but  one 
depression  will  be  observed  in  front  of  the  ear ; the  mouth  will  be 
less  widely  opened,  and  speech  and  deglutition  interfered  with  in  a 
less  degree. 

Prognosis. — In  recent  cases  the  reduction  is  always  easy,  and  the 
jaw  will  be  restored  to  the  full  enjoyment  of  its  functions.  More  dif- 
ficulty will  be  encountered  in  those  of  longer  standing.  Stromeyer 
; reduced  a dislocation  of  thirty-five  days’  standing,  and  Donava  one  of 
ninety  days.  To  facilitate  the  operation  in  such  instances  it  has 
been  proposed  to  divide  the  masseter  and  internal  pterygoid  muscles 
subcutaneously. 

Treatment. — The  indications  of  treatment  are,  to  reduce  the  disloca- 
tion and  to  prevent  subsequent  displacements,  to  which  there  is 
always  a tendency  for  some  time  afterwards. 

To  accomplish  the  former  object  many  plans  have  been  suggested. 
The  common  one  is  to  seat  the  patient  upon  the  floor  or  a low  stool  ; 
the  surgeon,  standing  in  front  of  him,  places  his  two  thumbs,  pre- 
viously wrapped  with  a bandage  to  protect  them  from  being  pinched 
between  the  teeth  when  the  jaws  come  together,  upon  the  molars, 
while  the  other  fingers  grasp  the  jaw,  and  presses  down-wards  to  dis- 
engage the  condyles ; then,  with  a sudden  movement,  he  elevates  the 
33 


514 


PARTICULAR  DISLOCATIONS. 


chin,  and  the  reduction  is  accomplished,  generally  with  an  audible 
snap. 

Sir  A.  Cooper  introduced  between  the  molars  little  wooden  wedges, 
or  the  handle  of  a knife  or  fork;  and  while  an  assistant  held  them  in 
position,  he  placed  himself  behind  the  patient,  and  dragged  the  chin 
upwards  by  means  of  a sling  placed  beneath  it. 

Eavaton  simply  elevated  the  chin,  making  a fulcrum  of  the  molar 
teeth. 

J.  L.  Petit  describes  a method  that  was  pursued  by  some  surgeons, 
consisting  in  striking  a strong  blow  with  the  fist  upon  the  under  sur- 
face of  the  chin,  in  some  of  the  cases  a piece  of  wood  having  been 
previously  interposed  between  the  jaws. 

Xelaton  recommends  the  thumbs  to  be  introduced  into  the  patient’s 
mouth,  and  pressure  be  made  upon  the  coronoid  apophysis  directly 
backwards,  the  other  fingers  taking  a point  d'appui  upon  the  mastoid 
processes;  this  pressure  may  even  be  made  externally  beneath  the 
malar  bone. 

Stromeyer  used  a specially  constructed  instrument,  provided  with 
forked  branches  fitting  the  dental  arches  above  and  below,  and  strong 
handles. 

For  fulfilling  the  second  indication,  that  of  preventing  the  disloca- 
tion recurring,  a sling-bandage  should  be  applied  to  the  jaw  to  main- 
tain it  at  rest  for  a week  or  ten  days,  then  exercise  it  gently,  that 
anchylosis  may  not  take  place;  the  patient  should  confine  himself 
to  fluid  or  pap-like  food  for  several  days. 

Sir  A.  Cooper  has  described  a condition  which  he  designates  as 
subluxation  of  the  jaw ; but  from  the  experiments  of  Xelaton  it  would 
seem  that  the  eminentia  articularis  does  not  offer  any  obstacle  to  the 
return  of  the  condyle  to  the  glenoid  cavity,  after  the  mouth  has 
been  widely  opened,  and  hence  there  is  nothing  short  of  a complete 
dislocation.  The  condition  alluded  to  occurs  particularly  in  scrofu- 
lous and  weakly  people,  whose  tissues  and  ligaments  are  relaxed,  and 
those  about  the  temporo-maxillary  articulation  perhaps  participating, 
may  allow  greater  play  to  the  inter-articular  cartilage,  enabling  it  to 
slip  behind  the  condyle,  and  thus  arrest  the  motion  of  the  jaw  sud- 
denly. This  happens  while  the  patient  is  eating  or  speaking;  the 
mouth  remains  half  open,  the  chin  slightly  advanced  forward ; and  he 
has  a sensation  as  if  the  condyle  had  slipped  from  its  place,  and  feels 
pain  upon  the  injured  side. 

The  malposition  of  the  cartilage  happens  especially  in  delicate 
females,  and  is  much  benefited,  and  even  cured,  by  tonic  medication. 
The  cartilage  will  easily  slip  into  place  by  slight  lateral  movements  of 
the  jaw,  or  with  the  hand  drawing  the  chin  downwards  and  forwards. 

Dislocation  of  the  Vertebra. — The  vertebrae  are  so  strongly 
bound  together  by  ligaments,  and  their  articular  surfaces  so  broad, 
that  they  are  rarely  found  dislocated ; indeed,  some  surgeons  have 
doubted  the  possibility  of  it  unless  associated  with  fracture.  There 
are,  however,  on  record  well-authenticated  cases  occurring  in  the  cer- 
vical region,  where  the  vertebras  enjoy  a much  greater  range  of 
motion  than  in  the  other  portions  of  the  spine ; yet  even  here,  fracture 


DISLOCATION  OF  THE  VERTEBRAE. 


515 


generally  accompanies  the  dislocation.  Luxation  of  the  occipito- 
atloid  articulation  will  be  followed  either  by  immediate  death,  or 
occurring  within  a very  short  period. 

From  the  greater  range  of  motion  in  the  atlo-axoid  articulation 
it  will  be  found  to  suffer  more  frequently  than  the  preceding  joint 
i from  dislocation. 

It  is  produced  by  falls  from  a height  upon  the  head,  violent  blows 
upon  the  nape  of  the  neck,  and  forced  flexion  of  the  head  upon  the 
chest.  It  has  also  been  known  to  occur  in  children  by  raising  them 
from  the  ground  by  the  head. 

The  transverse  ligament  of  the  atlas  is  either  ruptured,  or  the  odon- 
toid process  slips  beneath  its  lower  border  and  is  thrown  against  the 
spinal  cord. 

The  five  lower  cervical  vertebrae  may  be  dislocated  forwards  or 
backwards,  the  dislocation  being  complete  or  incomplete  according  as 
the  articulating  processes  are  wholly  or  partially  separated  from  each 
other.  If  these  are  equally  advanced,  the  luxation  is  bilateral,  and 
unilateral  when  only  one  process  is  thrown  forward,  while  the  other 
retains  its  connection.  Complete  dislocation  usually  terminates  fatally 
in  a day  or  two,  while  incomplete  and  unilateral  dislocation  may  lin- 
ger on  some  time  longer,  from  four  to  six  weeks. 

The  dorsal  vertebrae  are  most  commonly  displaced  posteriorly,  the 
fifth,  eleventh,  and  twelfth  pieces  being  those  most  usually  observed 
to  suffer ; and  the  dislocation  is  almost  invariably  associated  with  frac- 
ture of  their  bodies  and  processes. 

Treatment. — The  correct  diagnosis  of  a dislocation  of  a vertebra  is 
extremely  difficult  in  most  cases ; and  this  fact,  perhaps,  has  deterred 
most  surgeons  from  any  active  interference  in  this  class  of  injuries  of 
the  spine.  In  several  instances,  however,  where  the  dislocation  has 
been  seated  in  the  cervical  vertebrae,  it  has  been  recognized  and  suc- 
cessfully reduced.  Mr.  Erichsen  says  he  has  seen  unilateral  disloca- 
tion of  the  cervical  vertebrae  reduced  by  the  surgeon  placing  his  knees 
against  the  patient’s  shoulders,  drawing  on  the  head,  and  then  turning 
it  into  position,  the  return  being  effected  with  a distinct  snap. 

In  Dr.  Ayres’  case  of  dislocation  of  the  fifth  cervical  vertebra, 
counter-extension  was  made  by  placing  two  folded  sheets  obliquely 
across  the  shoulders  properly  secured,  and  extension  by  the  hands  of 
the  surgeon,  one  being  placed  under  the  chin  and  the  other  over  the 
occiput ; the  traction  being  made  first  in  the  direction  in  which  the 
head  was  thrown,  or  directly  backwards,  and  then  upwards.  The 
patient  had  been  thoroughly  anaesthetized  before  the  manipulations 
were  commenced,  and  the  bones  were  distinctly  felt  to  slip  into  their 
places. 

Dr.  Graves,  of  Hew  Hampshire,  reported  a case  of  dislocation  of  the 
last  dorsal  vertebra  successfully  reduced  by  extension  and  counter- 
extension from  the  armpits  and  hips ; the  patient  was  placed  upon  his 
face,  and  chloroform  administered  until  he  was  completely  under  its 
influence. 

These  cases  will  serve  to  illustrate  the  general  method  of  procedure 
in  dislocation  of  the  vertebrae. 


516 


PARTICULAR  DISLOCATIONS. 


Dislocation  of  the  Sternum. — This  dislocation,  which  is  very 
rare,  occurs  at  the  junction  of  the  first  with  the  second  piece  of  the 
sternum.  In  early  life  these  pieces  are  connected  together  by  carti- 
lage and  two  ligaments,  anterior  and  posterior ; in  rare  cases  a true 
arthrodial  joint  is  formed. 

The  form  of  displacement  which  has  been  observed  in  the  ten  recorded 
cases  of  this  injury,  consists  in  the  lower  extremity  of  the  manu- 
brium being  depressed  below  the  level  of  the  body  of  the  sternum. 

Causes. — Direct  violence  upon  the  sternum,  as  from  a heavy  blow 
with  a club,  and  falls  from  a height  upon  the  head  and  nates  or  lower 
extremities.  The  mechanism  of  the  dislocation  from  the  two  latter 
causes  is  explained  in  this  manner.  When  a person  falls  upon  the 
head  the  weight  of  the  body  forces  the  chin  violently  against  the 
sternum  and  depresses  the  manubrium.  The  same  result  will  follow 
if  the  person  alights  upon  the  nates ; the  neck  will  be  violently  flexed 
throwing;  the  chin  against  the  chest. 

Symptoms. — The  symptoms  of  this  injury  are — pain  over  the  ster- 
num, increased  by  pressure  and  the  respiratory  movements;  when  the 
finger  is  passed  from  the  top  of  the  sternum  downwards  it  will  en- 
counter the  projection  formed  by  the  upper  extremity  of  its  body. 

Prognosis. — Dislocation  of  the  sternum  is  always  a serious  injury, 
being  accompanied  in  the  majority  of  cases  with  dangerous  lesions  of 
the  organs  of  the  thoracic  and  cerebro-spinal  cavities. 

Treatment—  The  efforts  of  the  surgeon  will  generally  be  confined  to 
combating  the  inflammatory  complications  as  they  arise;  while  if  it 
should  be  deemed  prudent  to  attempt  the  reduction  in  consequence  of 
the  pressure  of  the  displaced  bone  upon  the  parts  beneath,  it  may  be 
accomplished  by  making  strong  pressure  upon  the  dorsal  region  from 
behind  forwards,  counter-pressure  being  established  at  the  same  time 
over  the  chin  and  pubis. 

AVhen  the  reduction  is  effected  place  a compress  on  the  seat  of 
injury,  and  confine  it  with  a body  bandage,  or  a broad  strip  of  adhesive 
plaster. 

Dislocation  of  the  Eibs  and  Costal  Cartilag-es. — The  ribs 
may  be  dislocated  upon  the  vertebrae,  upon  the  sternum,  and  upon 
each  other.  Saurel  also  speaks  of  chondro-costal  dislocation : but  as 
there  are  no  true  joints  between  the  ribs  and  their  cartilages  a sepa- 
ration at  this  point  should  rather  be  regarded  as  a fracture. 

From  the  nature  of  the  connections  of  the  ribs  with  the  vertebra 
by  strong  ligamentous  bands,  some  surgeons  have  doubted  the  possi- 
bility of  a dislocation,  yet  unquestionable  instances  of  the  kind  are 
upon  record,  and  particularly  of  the  lower  ribs.  It  is,  perhaps,  true, 
however,  that  in  most  cases  there  will  be  found  associated  with  a dis- 
location fracture  of  the  transverse  process  of  the  vertebra,  or  of  the 
necks  of  the  adjoining  ribs. 

The  injury  will  in  all  cases  be  found  to  result  from  heavy  blows 
upon  the  back ; the  displacement,  which  occurs  in  most  cases  is  in- 
wards. 

Symptoms. — It  will  be  exceedingly  difficult  to  make  out  a clear  diag- 
nosis in  these  cases  from  their  similarity  to  fracture  of  the  necks  ot 


DISLOCATIONS  OF  THE  UPPER  EXTREMITIES.  517 

I the  ribs.  Chelius  says  "that  dislocation  of  the  rib  may  be  distinguished 
by  its  greater  mobility,  when  the  finger  is  run  along  it,  and  which  is 
still  more  perceptible  the  nearer  it  approaches  the  hinder  end;  by  a 
particular  rustling  (which  is  not  to  be  confused  with  that  from  frac- 
tured rib,  or  from  emphysema),  which  is  perceived  on  the  movements 
of  the  body  and  ribs  by  the  practitioner,  or  by  the  patient  himself; 
by  a yielding  of  the  parts  covering  the  hinder  end  of  the  rib ; by  a 
depression  where  the  head  of  the  rib  should  be  found,  and  by  motion 
of  the  hind  end  on  pressure  of  the  front  end.  It  is  accompanied  with 
cough,  difficult  respiration,  severe  pain,  and  other  symptoms,  as  in 
fractured  ribs.” 

The  reduction  may  be  attempted  by  placing  the  patient  upon  his 
back  upon  a firm  mattress,  and  making  firm  pressure  upon  the  ante- 
rior extremity  of  the  ribs  so  as  to  force  its  head  backwards  into  its 
natural  position.  Compresses  may  then  be  laid  over  the  front  and 
back  of  the  chest,  and  confined  by  a thoracic  bandage. 

The  costal  cartilages  may  be  dislocated  upon  one  another,  particu- 
larly the  seventh  upon  the  eighth,  the  eighth  upon  the  ninth,  and  the 
ninth  upon  the  tenth,  between  which  there  are  joint-surfaces  incrusted 
with  cartilage,  lined  with  synovial  membrane,  and  connected  by  liga- 
ments. 

The  injury  results  from  the  violent  bending  backwards  of  the  body, 
and  presents  the  following  symptoms : acute  pain  over  the  cartilage 
from  any  exertion,  prominence  of  the  overlapping  piece,  with  a cor- 
responding depression  by  its  side  over  the  piece  beneath ; some  dis- 
turbance of  the  respiration,  and  a dull  creaking  sound  may  be  heard 
when  the  chest  walls  move  in  forced  breathing. 

The  reduction  is  easily  effected  by  directing  the  patient  to  bend  his 
body  backward,  and  making  pressure  upon  the  displaced  cartilage, 
over  which  a compress  is  now  to  be  placed,  and  confined  by  a body 
bandage. 

A chondro-sternal  dislocation  may  take  place  by  the  cartilage  being 
depressed  beneath  the  sternum.  It  generally  happens  in  children  of 
weakly  constitution,  and  will  be  recognized  by  a depression  at  the 
seat  of  injury;  the  reduction  may  be  attempted  by  directing  the 
patient  to  take  deep  inspirations.  The  after-treatment  requires  the 
■thoracic  walls  to  be  kept  at  rest  by  a broad  bandage. 

SECTION  II. 

DISLOCATIONS  OF  THE  UPPER  RXTREMITIES. 

Dislocation  of  the  Clavicle. 

I.  Inner  Extremity. 

1.  Forwards. 

2.  Upwards. 

3.  Backwards. 

II.  Outer  Extremity. 

1.  Upwards. 

2.  Downwards. 

3.  Downwards  under  coracoid  process. 

III.  Dislocation  of  Both  Extremities. 


518 


PARTICULAR  DISLOCATIONS. 


I.  Dislocation  of  the  Inner  Extremity  of  the  Clavicle.— 
The  inner  extremity  of  the  clavicle  is  held  in  connection  with  the 
sternum  by  a capsular  ligament  forming  a joint,  divided  into  two  com- 
partments by  an  inter-articular  cartilage,  in  the  same  manner  as  seen 
in  the  temporo-maxillary  articulation.  This  connection  is  still  farther 
strengthened  by  a ligament  passing  between  the  two  clavicles,  and  also 
one  between  the  clavicle  and  first  rib,  which  all  together  form  an  arti- 
culation of  considerable  strength ; so  that  it  is  uncommon  to  find  a 
dislocation  at  this  point.  When  it  does  happen,  the  displacement  may 
occur  in  either  one  of  three  directions ; forwards,  upwards,  or  back- 
wards; the  former  being  the  most  frequent. 

1.  Dislocation  forwards. — It  may  be  complete  or  incomplete;  in  the 
former  case,  the  capsular  ligament  will  be  torn  through ; the  inter- 
articular  cartilage  will  sometimes  be  carried  forwards  with  the  end  of 
the  clavicle,  and  sometimes  remain  connected  with  the  sternum ; the 
costo-clavicular  ligament  will  be  much  stretched,  frayed,  or  even  torn ; 
in  the  latter  the  capsular  ligament  is  only  forcibly  stretched. 

Causes. — The  most  common  cause  of  this  variety  of  luxation  is 
some  sort  of  .violence  applied  to  the  back  part  of  the  shoulder,  which 

drives  the  clavicle  obliquely  forwards 
and  inwards,  as  when  a person  falls 
upon  the  shoulder  from  a height. 
(Fig.  458).  Other  causes  have  also 
produced  it;  pressure  of  the  shoul- 
ders together  by  being  caught  between 
a carriage  wheel  and  a wall;  falls 
upon  the  elbow  when  the  arm  is 
thrown  forward ; muscular  exercise, 
in  swinging  the  dumb-bells,  or  en- 
deavoring to  support  a weight  upon 
the  head  or  shoulders.  Boyer  has 
seen  a case  in  a young  girl  who  sud- 
denly threw  her  shoulders  backwards 
to  assume  a more  graceful  attitude. 

Symptoms. — At  the  time  of  the  in- 
jury some  pain  will  be  felt  at  the  top 
of  the  sternum,  upon  the  front  of  which  a hard  tumor  formed  by  the 
extremity  of  the  clavicle  will  be  seen,  which  changes  its  position 
when  the  shoulder  is  moved ; the  sterno-clavicular  articulation  pre- 
sents a depression  instead  of  its  natural  prominent  outline.  The 
shoulder  is  raised  with  difficulty,  thrown  backwards,  and  brought 
nearer  the  median  line;  in  tracing  the  line  of  the  clavicle  with  the 
fingers  it  will  be  found  to  be  more  oblique,  running  forwards  and 
downwards  and  inwards  from  the  shoulder ; the  clavicular  portion  of 
the  tendon  of  the  sterno-cleido-mastoid  muscle  is  prominent  and 
tense;  the  head  of  the  patient  inclines  to  the  injured  side. 

Prognosis. — This  luxation  is  not  attended  with  danger,  and  though 
the  surgeon  may  not  be  able  to  keep  it  reduced,  little  injury  is  inflicted 
thereby  upon  the  functions  of  the  limb. 


Dislocation  of  the  sternal  end  of  the 
clavicle  forwards. 


DISLOCATION  OF  INNER  EXTREMITY  OF  CLAVICLE.  519 

Treatment. — The  indications  of  treatment  are,  first,  to  reduce  the 
luxation,  and  second,  to  maintain  it  thus  until  the  lacerated  ligaments 
shall  have  regained  sufficient  strength  to  prevent  any  further  dis- 
placement. 

For  fulfilling  the  first  indication,  the  patient  is  seated  upon  a chair, 
the  surgeon  standing  behind  him  places  his  right  knee  between  the 
scapulae,  and  seizing  the  two  shoulders  in  his  hands  he  draws  them 
back,  which,  with  a little  pressure  upon  the  displaced  extremity  of  the 
bone,  will  effect  the  reduction:  or  he  may  accomplish  the  same  object 
by  making  a lever  of  the  arm  of  the  injured  side;  while  the  left  hand 
supports  the  corresponding  axilla,  his  right  is  used  to  grasp  the  elbow, 
and,  carrying  it  backwards,  he  forces  the  clavicle  into  its  natural 
position. 

To  answer  the  second  indication,  various  apparatus  have  been  pro- 
posed, yet  it  is  very  difficult,  in  many  instances,  to  succeed  with  any 
of  them.  It  is  fortunate,  therefore,  that  so  little  inconvenience  results 
from  au  unreduced  luxation. 

A very  simple  plan  is  recommended  by  Nekton,  who  employed  an 
ordinary  hernial  truss,  the  anterior  pad  of  which  is  intended  to  make 
pressure  over  the  sterno-clavicular  articulation,  while  the  posterior  one 
takes  a point  d'appui  in  the  axilla  of  the  sound  side. 

M.  Melier  made  use  of  the  apparatus  of  Brasdor  for  fractured  cla- 
vicle, to  the  dorsal  plate  of  which  he  fastened  a steel  spring  curving 
over  the  injured  shoulder,  and  furnished  at  its  end  with  a concave  pad 
. for  making  pressure  upon  the  inner  extremity  of  the  clavicle. 

Sir  A.  Cooper  recommended  an  apparatus  consisting  of  two  padded 
rings  for  the  shoulders  buckling  to  two  dorsal  plates,  which  are  to  be 
drawn  together  by  straps  ; to  prevent  the  plates  being  displaced  up- 
wards, two  straps  also  connect  them  with  a belt  encircling  the  body. 

Whichever  apparatus  is  employed,  it  will  be  necessary  to  keep  it 
on  the  patient  six  or  eight  weeks,  or  even  longer,  in  order  to  overcome 
the  disposition  to  reluxation. 

2.  Dislocation  upwards. — This  is  a rare  accident,  and  appears  to  have 
resulted  in  a majority  of  the  recorded  cases  from  a force  acting  upon 
the  shoulder,  pressing  it  downwards. 

When  the  luxation  is  complete,  the  ligaments  are  ruptured  as  in  the 
preceding  case. 

Symptoms. — The  inner  extremity  of  the  clavicle  is  found  forming  a 
tumor  upon  the  top  of  the  sternum;  or,  perhaps,  as  seen  in  one  case, 
is  driven  across  the  median  line  beneath  the  sterno-cleido-mastoid 
muscle  of  the  opposite  side;  the  space  between  the  clavicle  and  first 
rib  is  increased,  and  at  its  bottom  the  semilunar  notch  upon  the  side 
of  the  sternum  may  be  felt;  the  shoulder  is  depressed  and  inclined  to 
the  front,  and  the  tendon  of  the  sterno-cleido-mastoid  is  shoved  promi- 
nently forward.  Should  the  end  of  the  clavicle  press  against  the 
trachea,  as  it  has  been  seen  to  do,  difficult  respiration  will  be  added  to 
the  rest  of  the  symptoms. 

Prognosis.— Considerable  difficulty  will  be  encountered  in  retaining 
the  bone  reduced  ; and  sometimes  it  is  found  impossible  ; but  in  this 


520 


PARTICULAR  DISLOCATIONS. 


case  even  the  patient  will  not  suffer  any  material  loss  of  power  in  the 
arm. 

Treatment. — The  reduction  is  easily  accomplished  by  drawing  the 
shoulder  upwards  and  slightly  backwards,  at  the  same  time  making 
pressure  upon  the  clavicle  from  above  downwards.  As  a retentive 
bandage,  Yelpeau  applied  his  apparatus  for  fractured  clavicle,  and 
kept  it  on  fifty  days  without  succeeding  in  keeping  the  luxation  re- 
duced. Malgaigne  believes  this  impossible  without  some  remaining 
deformity.  A gutta-percha  splint  may  be  moulded  to  the  clavicle  and 
ribs,  and  sustained  in  position  by  a roller  bandage  passing  around  the 
elbow  and  over  the  shoulder,  and  terminated  by  a few  turns  encircling 
the  chest  and  arm,  to  retain  the  latter  at  rest. 

3.  Dislocation  backwards.- — This  kind  of  dislocation  has  been  seen 
in  thirteen  or  fourteen  cases  on  record ; the  inner  extremity  of  the 
clavicle  takes  its  position  beneath  the  sterno-hyoid  muscle,  and  is  in- 
clined in  some  cases  upwards,  and  in  others  downwards. 

Causes. — In  a majority  of  the  recorded  cases  the  injury  has  resulted 
from  crushing  violence  applied  to  the  upper  part  of  the  chest ; in  a 
few  instances  from  the  shoulders  being  violently  pressed  together 
between  two  objects;  or  from  falls  upon  the  shoulder  forcing  it  from 
behind  forwards. 

Symptoms. — The  symptoms  are,  difficulty  in  moving  the  shoulder 
and  arm;  the  shoulder  approaches  nearer  the  median  line,  and  if  the 
inner  end  of  the  clavicle  inclines  downwards,  it  will  be  elevated ; or  it 
will  be  depressed  if  the  inclination  is  in  the  opposite  direction  ; in  the 
former  case  the  slope  of  this  bone  being  inwards  and  downwards,  and 
in  the  latter  inwards  and  upwards.  A depression  will  exist  over  the 
semilunar  notch  into  which  the  finger  may  be  thrust ; and  the  patient’s 
head  inclines  to  the  uninjured  side.  There  is  sometimes  embarrass- 
ment of  the  respiration  from  pressure  of  the  end  of  the  clavicle  upon 
the  trachea. 

Prognosis. — In  those  cases  in  which  reduction  has  not  been  accom- 
plished, the  functions  of  the  arm  have  not  been  impaired. 

Treatment.- — The  replacement  of  the  end  of  the  clavicle  in  the  semi- 
lunar notch  may  be  effected  by  drawing  the  shoulder  upwards,  out- 
wards, and  slightly  backwards,  and  the  reduction  should  be  maintained, 
if  possible,  by  the  posterior  figure  of  8 bandage,  and  a pad  laid  be- 
tween the  scapula.  The  same  object  may  also  be  obtained  by  placing 
the  patient  upon  his  back  with  a small  pillow  between  his  shoulders. 

II.  Dislocation  of  the  Outer  Extremity  of  the  Clavicle. — 
Dislocations  of  the  outer  extremity  of  the  clavicle  are  much  more  com- 
mon than  those  of  the  inner.  Its  articulation  with  the  acromion  pro- 
cess is  less  broad  and  less  firmly  bound  together  with  strong  ligaments 
than  at  the  sternum,  ivhile  the  position  of  the  joint  at  the  tip  of  the 
shoulder  is  more  exposed  to  the  action  of  external  forces.  YThen  de- 
tached from  its  natural  connections  with  the  scapula,  the  acromial  end 
of  the  clavicle  may  be  displaced  upwards,  downwards,  or  downwards 
beneath  the  coracoid  process. 

1.  Dislocation  upwards. — This  is  the  most  common  variety  of  the 


DISLOCATION  OP  OUTER  EXTREMITY  OF  CLAVICLE.  521 


and  is  either  com- 


Fig.  459. 


Dislocation  of  the  onter  end  of  the 
clavicle,  upwards  and  outwards. 


luxations  of  the  acromial  extremity  of  the  clavicle  : 
plete  or  incomplete.  In  the  former  case, 
the  ligaments  surrounding  the  joint  will 
he  completely  ruptured,  and  the  point  of 
the  clavicle  will  either  rest  upon  the  edge 
of  the  upper  surface  of  the  acromion  pro- 
cess, or  project  across  it  to  the  extent  of 
half  or  three-quarters  of  an  inch. 

Causes. — The  common  cause  producing 
this  dislocation  is  a fall  upon  the  point  of 
the  shoulder  while  the  arm  rests  along 
side  of  the  body.  Malgaigne  mentions  a 
case  produced  by  a fall  upon  the  elbow, 
and  Nekton  another  from  a heavy  weight 
striking  the  clavicle  from  above. 

Symptoms. — The  symptoms  are,  pain  at 
the  seat  of  the  injury;  the  shoulder  is 
slightly  depressed  and  somewhat  nearer 
the  median  line,  the  patient  has  great  dif- 
ficulty in  abducting  the  arm,  which  hangs 
by  his  side ; and  in  most  cases  he  cannot 
place  the  hand  upon  his  head ; the  arm 

can,  however,  be  moved  freely  backwards  and  forwards.  The  end  of 
the  clavicle  will  be  found  forming  a hard  tumor  upon  the  top  of  the 
shoulder,  terminating  externally  by  a depression;  in  passing  the  fin- 
ger along  the  spine  of  the  scapula,  acromion,  and  clavicle,  the  latter 
will  be  felt  thrown  out  of  the  continuous  line  which  they  naturally 
form. 

Diagnosis. — This  injury  has  been  mistaken  for  fracture  of  the  clavi- 
cle and  dislocation  of  the  head  of  the  humerus:  but  a careful  compa- 
rison of  the  above  symptoms  and  those  of  these  two  accidents  will 
certainly  prevent  any  blunder. 

Treatment. — The  reduction  is  accomplished  by  carrying  the  shoul- 
der upwards  and  outwards,  while  at  the  same  time  pressure  is  made 
with  the  fingers  upon  the  displaced  bone.  Here  the  difficulty  begins; 
for  despite  the  application  of  the  most  ingenious  contrivances  the 
bone  will  generally  slip  from  its  place  again  and  again.  Should  the 
dislocation  remain  unreduced,  little  harm  comes  of  it,  as  the  patient 
can  use  his  arm  with  as  much  freedom  as  though  nothing  had  hap- 
pened. 

The  apparatus  of  Bartlett  for  fractured  clavicle  has  sometimes  suc- 
ceeded; an  additional  strap  is  employed,  which  passes  over  the  injured 
shoulder,  and  forces  the  clavicle  downwards  ; and  thus  counteracts  the 
action  of  the  clavicular  insertion  of  the  trapezius  muscle. 

The  apparatus  of  Desault  answers  the  same  indication,  inasmuch  as 
the  third  roller  encircles  the  shoulder  and  elbow. 

M.  Baraduc  has  suggested  a somewhat  similar  bandage;  he  encir- 
cles the  arm  with  the  turns  of  a roller  to  prevent  the  other  parts  of 
the  dressing  slipping,  and  places  it  by  the  side  of  the  chest;  the  first 


522 


PARTICULAR  DISLOCATIONS. 


roller  is  applied  circularly  around  the  arm  and  chest,  and  compresses 
are  placed  upon  the  top  of  the  shoulder,  the  luxation  having  been 
previously  reduced ; then  a second  roller  is  made  to  pass  over  the 
shoulder,  and  under  the  elbow  until  seven  or  eight  turns  are  laid  on, 
and  these  are  prevented  from  slipping  by  circular  turns  around  the 
chest  and  arm. 

It  has  been  attempted  to  make  the  necessary  amount  of  pressure 
upon  the  clavicle  with  the  ordinary  tourniquet,  the  pad  being  placed 
upon  the  shoulder  and  the  straps  buckled  beneath  the  corresponding 
elbow. 

Malgaigne  has  devised  an  apparatus  consisting  of  a strongly  woven 
band  about  four  inches  wide,  and  long  enough  to  reach  around  the 
shoulder  and  elbow ; one  of  its  ends  is  furnished  with  a buckle,  and 
the  other  with  a strap  ; between  these  an  elliptical  piece  is  cut  from 
the  band.  To  apply  it,  place  compresses  over  the  acromial  end  of  the 
clavicle,  and  upon  the  elbow ; slip  the  elbow  into  the  elliptical  hole  of 
the  band,  which  must  now  be  buckled  over  the  shoulder;  to  prevent 
the  band  slipping  from  the  clavicle,  a thoracic  strap  should  be  attached 
to  it,  passing  around  the  uninjured  side. 

M.  Mayor  recommends  the  apparatus  seen  in  Fig.  460.  It  consists 
of  a sling  for  the  forearm,  and  two  broad  belts  passing  over  the 

shoulders,  and  attached  to  it  in 
front. 

2.  Dislocation  downwards. — 
It  is  a rare  form  of  luxation,  and 
but  three  cases  have  been  re- 
corded. It  results  from  blows 
upon  the  top  of  the  shoulder, 
which  displace  the  acromial  end 
of  the  clavicle  downwards  be- 
neath the  acromion  process,  and 
between  it  and  the  capsular  lig- 
ament of  the  head  of  the  hume- 
rus, and  is  accompanied  with  a 
rupture  of  the  acromio-clavicu- 
lar,  coraco-acromial,  and  coraco- 
clavicular  ligaments. 

Symptoms . — The  clavicle 
slopes  outwards;  a depression 
will  be  felt  over  the  acromio- 
clavicular articulation,  and,  fur- 
ther outwards,  an  eminence, 
formed  by  the  projection  of  the 
acromion  process  and  the  inferior  angle  of  the  scapula,  projects  back- 
wards. The  arm  can  be  moved  freely  forwards  and  backwards,  but  the 
motion  of  abduction  will  be  much  more  restricted. 

Treatment. — The  reduction  in  this  case  is  accomplished  by  drawing 
the  shoulders  outwards,  the  knee  of  the  surgeon  having  been  previ- 
ously placed  between  the  scapulae. 


Fig.  460. 


Apparatus  of  Mayor  for  dislocation  of  the  clavicle. 


DISLOCATION  OF  THE  HUMERUS. 


523 


There  was  no  disposition  to  relaxation  in  the  cases  observed. 

M.  Tournel  employed  in  his  case  at  first  the  bandage  of  Desault  for 
fracture  of  the  clavicle,  and  afterwards  that  of  Flamand  ; the  cure  was 
complete  on  the  thirty-second  day. 

8.  Dislocation  downwards  under  Coracoid  Process.  — Dislocation 
downwards  under  the  coracoid  process  is  also  a rare  form  of  luxation, 
there  being  six  cases  on  record.  It  is  caused  by  falls  upon  the  shoul- 
der ; and  has  in  the  larger  number  of  instances  been  observed  among 
persons  advanced  in  age. 

Symptoms. — The  symptoms  are  depression  and  slight  inclination 
forwards  of  the  shoulder ; when  the  finger  is  passed  along  the  border 
of  the  acromion  process  forwards,  the  clavicular  prominence  is  found 
wanting,  while  the  coracoid  and  acromion  project  boldly  forwards ; 
the  clavicle  slopes  outwards,  and  its  distal  extremity  can  be  felt  in  the 
axilla.  The  inferior  angle  of  the  scapula  is  pushed  outwards  and 
backwards. 

Treatment. — To  replace  the  luxated  bone  bring  the  elbow  of  the 
injured  arm  to  the  side  of  the  chest,  and  while  the  surgeon  supports 
it  here  in  his  left  hand  he  puts  his  right  hand  in  the  axilla,  and  draws 
the  upper  extremity  of  the  humerus  outwards.  After  the  reduction 
confine  the  arm  to  the  side,  and  support  the  forearm  in  a sling. 

III.  Dislocation  of  Both  Extremities  of  the  Clavicle.  — M. 
Porral  reports  one  case  of  this  dislocation,  and  M.  Gfoffres  another. 
The  latter  happened  in  a woman  from  a fall  between  two  rocks ; there 
were  ecchymoses  upon  the  anterior  \ and  external  faces  of  the  right 
shoulder;  the  internal  extremity  of  the  right  clavicle  was  incompletely 
luxated  forwards,  and  the  outer  extremity  upwards.  The  reduction 
was  easily  accomplished,  but  could  not  be  maintained  ; and  the  patient 
was  abandoned  to  her  fate,  the  arm  and  forearm  being  supported  in  the 
scarf  bandage  of  M.  Mayor.  At  the  end  of  forty  days  this  was  removed, 
and  the  patient  resumed  her  occupation  without  the  least  restraint  of 
motion  of  the  arm,  notwithstanding  the  persistence  of  the  clavicular 
displacement. 

Dislocation  of  the  Humerus. 

From  the  nature  of  the  anatomical  structure  of  the  shoulder-joint, 
dislocation  of  the  humerus  is  quite  common.  It  may  occur  in  one  of 
three  directions. 

1.  Downwards. 

2.  Forwards. 

3.  Backwards. 

1.  Dislocation  downwards. — This  is  by  far  the  most  frequent  variety, 
a fact  readily  explainable  when  the  anatomical  arrangement  of  the 
shoulder-joint  is  examined.  The  acromion  and  coracoid  processes, 
with  their  ligaments,  form  a strong  and  resistant  protection  above, 
in  front,  and  behind,  while  below  there  is  nothing  to  prevent  the 
head  of  the  humerus  slipping  from  the  shallow  glenoid  cavity  but 
the  resistance  offered  by  a thin  capsular  ligament,  and  by  muscular 
contraction. 

Causes. — The  causes  are  direct  force  applied  to  the  shoulder,  as 


524 


PARTICULAR  DISLOCATIONS. 


happens  in  falls ; blows  upon  the  upper  part  of  the  arm ; falls  upon 
the  elbow  or  hands  when  the  arms  are  thrown  forwards ; and  muscu- 
lar action. 

Mechanism. — When  a blow  is  struck  upon  the  shoulder,  the  head 
of  the  humerus  is,  of  course,  driven  directly  from  the  glenoid  cavity; 
and,  perhaps,  in  a majority  of  these  instances,  the  arm  at  the  time  of 
the  injury  is  more  or  less  abducted. 

Indirect  force  upon  the  hand  or  elbow  luxates  the  head  of  the  bone 
by  making  a lever  of  the  first  kind  of  the  humerus,  the  fulcrum  being 
formed  by  its  tuberosity  coming  against  the  margin  of  the  glenoid 
cavity,  and  the  point  of  resistance  by  the  anterior  and  inferior  part  of 
the  capsular  ligament,  which  is  usually  considerably  torn  in  front  of 
the  tendon  of  the  long  head  of  the  biceps  ; and  even  the  latter  is  some- 
times ruptured,  allowing  the 
head  of  the  bone  to  escape 
from  the  capsule  and  take  a 
position  beneath 
cavity  upon  the  s 
muscle  near  the  triangular 
space  of  the  inferior  border  of 
the  scapula. 

The  supra -spinatus,  infra- 
spinatus, subscapularis,  coraco- 
brachialis,  and  deltoid  muscles 
are  much  stretched,  and  some 
of  them,  in  certain  cases,  rup- 
tured. 

Symptoms. — The  symptoms 
are  : unusual  prominence  of  the 
acromion  process,  and  flatten- 
ing of  the  deltoid  muscle;  the 
head  of  the  humerus  can  be 
felt  in  the  axilla ; the  arm  sepa- 
rated from  the  chest  slopes  out- 
Avards  and  sometimes  a little 
backwards,  and  cannot  be  brought  in  contact  with  it,  though  the  arm 
may  be  moved  to  some  extent  forwards  and  backwards ; it  is  also 
slightly  longer  than  the  other  arm ; the  forearm  is  flexed  a little 
upon  the  arm,  and  the  patient  cannot  place  the  hand  of  the  injured 
limb  upon  the  opposite  shoulder ; the  head  and  neck  incline  to  the 
injured  side.  Crepitus  is  sometimes  heard  when  the  arm  is  moArnd, 
probably  depending  upon  erosion  of  the  cartilage  of  the  joint,  and 
should  put  the  surgeon  on  his  guard  not  to  mistake  it  for  the  crepitus 
caused  by  a fracture. 

Prognosis. — There  will  be  no  trouble  in  reducing  a recent  disloca- 
tion, and  in  many  cases  it  has  been  effected  after  the  lapse  of  weeks 
and  even  months,  sometimes  by  manipulation,  at  others  with  certain 
mechanical  contrivances. 

If  the  injury  to  the  joint  has  not  been  very  severe,  the  arm  will  be 


the  glenoid 
ubscapularis 


Fig.  461. 


Dislocation  of  the  shoulder  downwards. 


DISLOCATION  OF  THE  HUMERUS. 


525 


restored  to  its  original  usefulness,  after  reduction.  In  other  instances, 
from  extensive  laceration  of  the  capsule,  rupture  of  the  tendon  of  the 


Fig.  462. 


External  appearance  of  dislocation  of  the  shoulder  downwards. 


biceps,  or  the  supra- spinatus,  or  from  some  other  cause,  the  arm 
remains  stiff,  and  its  functions  impaired  for  months;  or  it  may  even 
become  paralyzed  and  atrophied  from  injury  to  the  circumflex  and 
other  nerves. 

In  some  cases  the  symmetry  of  the  joint  fails  to  be  restored,  the 
head  of  the  humerus  projecting  considerably  in  front;  and  this  may 
give  rise  to  the  supposition  that  the  bone  has  been  unreduced. 

Treatment. — Many  methods  have  been  suggested  by  surgeons,  for 
the  reduction  of  dislocation  of  the  shoulder,  from  the  time  of  Hippo- 
crates to  the  present  moment. 

The  chief  obstacle  to  the  reduction  is  the  tension  of  the  muscles, 
in  which  the  supra-spinous  and  deltoid  are  principally  in  fault.  The 
simple  plan  of  relaxing  these  two  muscles  by  carrying  the  elbow 
away  from  the  chest  will  often  suffice  alone  to  return  the  bone.  M. 
Lacour  directs  the  patient  to  be  seated  upon  a stool,  an  assistant  stand- 
ing upon  the  uninjured  side  fixes  the  scapula  with  his  hands;  the 
surgeon  now  seizes  the  arm,  bends  the  forearm  at  right  angles  with  it, 
and  makes  extension,  at  the  same  time  carrying  the  elbow  from  the 
body  until  the  arm  is  at  right  angles  with  it ; then  using  the  forearm  as 
a lever,  he  rotates  the  humerus  rapidly  inwards  and  brings  the  elbow 
to  the  chest,  when  the  reduction  will  be  completed. 

Some  difficulty  has  been  encountered  in  effecting  the  reduction  by 
extension  in  fixing  the  scapula  so  that  it  may  become  a fixed  point  of 
counter-extension.  To  remedy  this  objection,  Desault  and  Boyer 


526 


PARTICULAR  DISLOCATIONS. 


advised  the  use  of  two  bands  to  fix  the  shoulder,  one  crossing  the 
acromion,  and  the  other  passing  beneath  the  axilla ; their  ends  were 
pulled  in  the  opposite  direction  to  that  of  extension  and  fastened  to 
a wall. 

For  the  same  purpose  Sir  A.  Cooper  used  an  apparatus  (Fig.  463) 
consisting  of  a broad  band  split  at  its  centre  to  receive  the  shoulder, 
and  having  its  two  ends  attached  to  a wall  in  the  same  manner  as  in 
the  previous  method ; the  extending  belt  is  fastened  around  the  lower 


Fig.  463. 


Sir  A.  Cooper’s  method  of  securing  the  scapula  with  a counter-extending  hand. 

part  of  the  arm  above  the  elbow ; the  forearm  is  bent  at  right  angles 
with  the  arm. 

Dr.  Nathan  Smith,  of  New  Haven,  endeavored  to  fix  the  scapula 
by  making  the  counter-extension  from  the  opposite  wrist,  and  his  son, 
Prof.  N.  R.  Smith,  of  Baltimore,  combines  the  methods  of  his  father  and 
Sir  A.  Cooper ; that  is,  he  uses  the  counter-extending  band  seen  in 
Fig.  464,  and  secures  the  wrist  of  the  sound  arm  to  it. 

A plan  was  pursued  by  Sir  A.  Cooper  of  making  the  extension  in  the 
line  of  the  body,  while  the  heel  was  pressed  into  the  axilla.  (Fig.  465.) 
Fie  placed  “the  patient  in  the  recumbent  posture  upon  a table  or  sofa, 
near  to  the  edge  of  which  he  is  to  be  brought.  The  surgeon  then 
binds  a wetted  roller  round  the  arm  immediately  above  the  elbow, 
upon  which  he  ties  a handkerchief ; then  he  separates  the  patient’s 
elbow  from  his  side,  and,  with  one  foot  resting  upon  the  floor,  he 
places  the  heel  of  his  other  foot  in  the  axilla,  receiving  the  head  of 
the  os  humeri  upon  it,  while  he  is  himself  in  the  sitting  posture  by 
the  patient’s  side.  He  then  draws  the  arms  by  means  of  the  hand- 
kerchief, steadily,  for  three  or  four  minutes,  when,  under  common 
circumstances,  the  head  of  the  bone  is  easily  replaced;  but  if  more 
force  be  required,  the  handkerchief  may  be  changed  for  a long  towel, 
by  which  several  persons  may  pull,  the  surgeon's  heel  still  remaining 


DISLOCATION  OF  THE  HUMERUS. 


527 


Smith’s  method. 

in  the  axilla.  He  generally  bent  the  forearm  nearly  at  right  angles 
-with  the  os_  humeri,  because  it  relaxes  the  biceps,  and  consequently 
diminishes  its  resistance.” 


Fig.  465. 


Fig.  464. 


Sir  A.  Cooper’s  mode  of  making  counter-extension  with  the  heel. 

This  distinguished  surgeon  employed  another  method  (Fig.  466), 
which,  though  not  near  so  powerful  as  the  preceding,  will  answer  very 


528 


PARTICULAR  DISLOCATIONS. 


Fig-  4fa'6-  well  in  those  cases  where  the  ligaments 

and  muscles  are  much  relaxed — as  in 
delicate  females.  The  patient  is  seated 
in  a chair,  the  surgeon,  standing  be- 
hind him,  and  upon  the  injured  side, 
places  his  foot  upon  the  seat  of  the 
chair,  with  his  knee  forced  well  up 
into  the  axilla,  and  then  steadying 
the  shoulder  with  one  hand,  he  grasps 
the  arm  with  the  other,  and  presses 
it  forcibly  downwards  and  inwards. 

Mr.  Skey  believed  that  it  was  best 
to  allow  the  scapula  to  have  free 
play,  so  that  the  glenoid  cavity  may 
be  drawn  downwards,  which  he  be- 
lieves will  contribute  to  the  reduc- 
tion. In  the  use  of  the  pulleys  he 
therefore  discards  the  use  of  the  band 
for  fixing  the  scapula,  and  adopts  a 
“ well-padded  iron  knob  (Fig.  467), 
which  may  represent  the  heel,  from 
which  there  extend  laterally  two 
strong,  straight  branches  of  the  same  metal,  each  ending  in  a bulb  or 
ring  of  about  four  inches  in  length,  the  office  of  which  is  designed  to  keep 


Sir  A.  Cooper’s  mode  of  reduction  with  the 
knee  in  the  axilla. 


Fig.  467. 


Skey’s  iron  knob  for  the  axilla. 


the  margins  of  the  axilla  as  free  from  pressure  as  possible.  The  person 
of  the  patient  should  be  placed  on  the  back,  or  inclined  over  on  to 

Fig.  468. 


Skey's  method  of  operating  with  the  iron  knob  and  pulleys. 


the  opposite  side,  and  the  cords  passed  up  on  each  side  of  the  shoulder, 
one  in  front  and  the  other  behind  the  joint  (Fig.  46S).  The  arm  should 
be  drawn  downwards,  as  nearly  as  possible  parallel  to,  and  in  contact 


DISLOCATION  OF  THE  HUMERUS. 


529 


with,  the  body.  Extension  should  be  made  from  the  wrist,  and,  espe- 
cially in  old  cases,  continued  gradually.  With  the  above  plan  he  has 
succeeded  in  reducing  a great  many  dislocations,  whether  occurring  in 
very  muscular  men,  or  after  some  days  or  weeks,  or  even  months’ 
duration.” 

In  the  methods  which  we  have  now  described,  extension  is  made 
downwards  in  the  line  of  the  body,  but  the  reduction  may  be  accom- 
plished by  making  extension  upwards  in  the  line  of  the  body.  This 
plan  seems  to  have  been  practised  by  Brunus  in  the  thirteenth  cen- 
tury; by  White,  towards  1762;  by  Mothe,  of  Lyons,  in  1776.  While 
the  arm  is  being  extended,  counter-extension  is  made  by  the  hand, 
foot,  or  knee  placed  on  the  top  of  the  shoulder.  White,  of  Manches- 


Fig.  469. 


Mothe's  method  of  reduction,  modified. 


ter,  attached  pulleys  to  the  ceiling,  and  hoisted  the  patient  from  the 
ground  by  a fillet  fastened  to  his  wrist. 

Malgaigne  directs  a handkerchief  to  be  bound  to  the  patient’s 
wrist,  and  its  two  extremities  tied  in  a loop,  which  is  thrown  over  the 
upper  corner  of  a door,  so  that  when  the  person  raises  his  feet  the 
weight  of  the  body  will  be  supported  by  the  handkerchief. 

Jarvis’s  adjuster  is  a powerful  instrument,  and,  manipulated  with 
care,  will  be  found  exceedingly  valuable  in  reducing  old  dislocations. 

In  all  cases  where  any  difficulty  is  encountered,  it  will  be  advisable 
to  put  the  patient  thoroughly  under  the  influence  of  chloroform,  both 
for  the  purpose  of  releasing  him  from  pain,  as  well  as  to  obtain  com- 
plete muscular  relaxation. 

In  making  extension  either  with  the  hands  or  with  pulleys,  the 
direction  should  be  nearly  downwards — or  certainly  not  higher  than 
an  angle  of  forty-five  degrees,  with  a view  to  obviate  the  actions  of 
the  pectoralis  major  and  latissimus  dorsi.  All  jerking  and  traction 
in  distorted  lines  can  accomplish  nothing  but  injury  to  the  patient. 
Reduction  of  many  ancient  dislocations  has  been  effected  by  Velpeau, 
Malgaigne,  Gibson,  and  others;  in  these  cases  the  redoubtable  acci- 
dents to  be  feared  are  rupture  of  the  axillary  nerves  and  bloodvessels, 
inflammation  of  the  tissues  about  the  joint,  and  swelling  and  emphy- 
sema of  the  shoulder  and  axilla. 

34 


530 


PARTICULAR  DISLOCATION'S. 


2.  Dislocation  forwards.  — This  kind  of  dislocation  presents  two 
species,  according  to  the  position  assumed  by  the  head  of  the  humerus. 
In  the  first  (subcoracoid),  seen  in  Fig.  470,  the  head  takes  its  position 
beneath  the  coracoid  process,  behind  the  tendon  of  the  coraco-brachi- 
alis  and  short  head  of  the  biceps,  and  lies  upon  the  subscapular  mus- 

Fig.  470.  Fig.  471. 


cle.  In  the  second  variety  (subclavicular)  (Fig.  471)  the  head  rests 
beneath  the  clavicle,  inside  of  the  coracoid  process,  and  behind  the 
pectoralis  major  and  minor  muscles,  upon  that  portion  of  the  serratus 
magnus  which  covers  the  second  and  third  ribs. 

The  capsular  ligament  will  usually  be  much  lacerated;  and  the  del- 
toid, supra-spinatus,  infra-spinatus,  and  subscapularis  muscles  much 
stretched,  and  the  latter  are  sometimes  ruptured. 

Causes. — The  cases  are  blows  upon  the  posterior  surface  of  the 
shoulder  driving  the  head  of  the  humerus  forwards;  falls  upon  the 
hands  or  elbow,  particularly  when  the  arms  are  inclined  backwards; 
the  continued  action  of  a force  upon  the  elbow  after  the  head  of  the 
bone  has  been  displaced  in  the  axilla  may  shove  the  head  either 
beneath  the  coracoid  or  clavicle ; and  lastly,  muscular  action. 

Symptoms. — The  acromion  will  project  markedly,  with  a depres- 
sion below,  very  evident  a little  posteriorly  ; the  head  of  the  humerus 
can  be  felt  in  the  subclavicular  fossa  forming  a distinct  hard  tumor, 
though  in  subcoracoid  dislocation  the  tumor  will  be  farther  from  the 
median  line  in  front  of  the  shoulder,  as  seen  in  Fig.  472  ; the  elbow  is 
close  to  the  side  of  the  body,  and  inclines  backwards;  the  arm  is 
slightly  shortened,  and  cannot  be  moved  without  causing  lively  pain; 
neither  the  surgeon,  nor  the  patient  himself  can  place  the  hand  of  the 
injured  arm  upon  the  opposite  shoulder;  and  lastly,  the  head  aud 
neck  incline  to  the  injured  side. 

Prognosis. — The  prognosis  in  uncomplicated  cases  is  as  favorable  as 
in  the  previous  variety;  but  the  reduction  becomes  much  more  diffi- 
cult after  the  lapse  of  a few  days. 

Treatment. — The  same  principles  of  treatment  hitherto  described  for 


Subcoracoid  dislocation. 


Subclavicular  dislocation. 


DISLOCATION  OF  THE  HUMERUS. 


531 


luxations  downwards  are  applicable  also  in  this  variety.  Both  Vel- 
peau and  Malgaigne  direct,  as  the  most  rational  practice,  that  the  arm 
he  extended  at  right  angles  to  the  chest. 


Fig.  472. 


Subcoracoid  dislocation. 


Fig.  473. 


3.  Dislocation  hacJeioarcls. — It  also  presents  two  varieties.  In  one 
the  head  of  the  humerus  takes  a position  beneath  the  acromion  (suba- 
cromial), and  in  the  other  beneath  the  spine  of  the  scapula  (sub- 
spinous). It  is  a rare  form  of  injury,  and  but  few  cases  have  been 
reported. 

Causes. — It  has  happened  chiefly  from  falls  upon  the  elbow  directed 
forwards,  of  upon  the  shoulder.  The 
head  of  the  humerus  ruptures  the  cap- 
sular ligament  at  its  posterior  part,  es- 
caping between  the  tendon  of  the  triceps 
and  the  inferior  angle  of  the  acromion, 
and  either  rests  beneath  this  process,  or 
passes  further  along  under  the  spine,  as 
seen  in  Fig.  473;  the  tendon  of  the  sub- 
scapularis  muscle  being  often  ruptured. 

The  head  of  the  bone  is  covered  in  by 
the  infra-spinatus,  teres  minor,  and  del- 
toid, though  it  sometimes  happens  that 
the  head  escapes  between  the  two  for- 
mer, and  is  found  beneath  the  deltoid 
only. 

Symptoms.  — Subacromial  depression 
will  be  well  marked,  and  the  coracoid  subspinous  dislocation. 


532 


PARTICULAR  DISLOCATIONS. 


process  will  be  seen  prominent  in  front;  the  head  of  the  humerus  can 
be  felt  beneath  the  spine  of  the  scapula ; the  elbow  is  close  to  the 
side,  and  projects  forwards  across  the  chest ; the  arm  is  slightly  longer 
than  the  opposite  one,  and  its  movements  are  restrained,  but  not  so 
much  so  as  in  the  other  varieties  of  dislocation. 

Treatment. — In  some  cases  the  simple  abduction  of  the  arm  has 
effected  the  reduction,  while  in  others  it  will  be  necessary  to  rotate 
the  arm  inwards  after  abducting  it. 

M.  Lacaussade  succeeded  perfectly  by  carrying  the  elbow  backwards, 
while  he  pressed  the  head  of  the  humerus  strongly  forwards. 

Dislocations  of  the  humerus  may  be  complicated  with  fracture 
through  its  anatomical  or  surgical  necks,  of  its  tuberosities  or  of  the 
coracoid  or  acromial  processes,  or  lastly,  of  the  glenoid  fossa. 

It  may  also  be  compound  or  complicated  with  injury  to  the  axillary 
nerves  and  bloodvessels.  In  treating  such  complications,  the  general 
rule  to  follow  is,  where  a fracture  is  present  endeavor,  if  possible,  to 
reduce  the  dislocation,  and  then  treat  the  case  as  one  of  fracture.  This 
cannot  always  be  done,  however;  and  the  surgeon  will  be  compelled 
to  wait  until  the  broken  bones  are  united,  and  afterwards  try  to  effect 
the  reduction. 

Aneurism  and  laceration  of  the  axillary  vessels  are  to  be  opposed, 
after  reduction,  by  the  means  directed  in  general  works  on  surgery. 

Dislocation  of  the  Radius  and  Ulna. 

I.  Dislocation  of  the  Radius  and  Ulna. 

1.  Backwards. 

2.  Forwards. 

3.  Outwards. 

4.  Inwards. 

5.  Radius  forward  and  ulna  backwards. 

II.  Dislocation  of  the  Radius. 

1.  Backwards. 

2.  Forwards. 

3.  Outwards. 

III.  Dislocation  of  the  Ulna. 

a.  Upper  extremity. 

Backwards. 

b.  Lower  extremity. 

1.  Forwards. 

2.  Backwards. 

I.  Dislocation  of  the  Radius  and  Ulna. — 1.  Dislocation  of  the 
Radius  and  TJlna  backwards. — It  may  be  complete  or  incomplete;  in 
the  former  case  the  coronoid  process  of  the  ulna  occupies  the  olecranon 
fossa,  while  the  head  of  the  radius  rests  above  the  epicondyle.  The 
condyles  of  the  humerus  force  the  brachialis  anticus  and  the  biceps 
strongly  forwards,  stretching  and  sometimes  lacerating  them : the 
brachial  artery  and  median  nerve  are  also  pressed  upon ; the  anterior 
and  lateral  ligaments  are  also  usually  torn  through  (Fig.  474). 

Causes. — The  causes  are  direct  blows  upon  the  upper  and  front  part 


DISLOCATION  OF  THE  RADIUS  AND  ULNA. 


538 


of  the  forearm,  or  upon  the  lower  and  back  part  of  the  arm  ; and  most 
commonly  falls  upon  the  hands  or  elbow  while  the  arms  are  thrown 

Fig.  474.  Fig.  475. 


Dislocations  of  the  radius  and  ulna  backwards. 

forwards ; violent  rotation  and  forced  flexion  of  the  forearm  may  also 
cause  it. 

Symptoms. — The  forearm  is  somewhat  flexed  and  shortened,  and  the 
functions  of  the  elbow-joint  nearly  abolished ; the  hand  is  supinated 
and  can  be  pronated  but  slightly;  the  olecranon  process  projects  pos- 
teriorly and  its  tip  will  be  some  distance  above  a transverse  line  con- 
necting the  epicondyles ; a tumor  is  formed  in  the  bend  of  the  elbow 
by  the  projecting  condyles  of  the  humerus  (Fig.  475). 

Prognosis. — In  simple  cases  the  reduction  may  be  effected  promptly, 
and  it  is  rare  for  any  bad  consequences  to  follow  if  much  injury  has 
not  been  inflicted  upon  the  joint ; however,  even  after  the  bones  are 
replaced,  the  motion  of  the  joint  will  be  much  impaired,  even  if  an- 
chylosis does  not  follow. 

Treatment. — There  are  several  simple  methods  of  reducing  a dislo- 
cated elbow.  The  first  is  that  practised  by  Nelaton  : the  forearm  is  to 
be  bent  at  right  angles  with  the  arm,  a short  splint  is  bound  to  the 
posterior  surface  of  the  arm  with  its  lower  edge  pressing  against  the 
olecranon ; then  the  surgeon  simply  extends  the  forearm,  when  the 
splint  will  force  the  olecranon  downwards  towards  its  fossa.  A second 
plan  (Fig.  476),  that  recommended  by  Sir  A.  Cooper,  consists  in  mak- 
ing the  patient  sit  upon  a chair,  “ and  the  surgeon,  placing  his  knee  on 
the  inner  side  of  the  elbow-joint,  in  the  bend  of  the  arm,  takes  hold  of 
the  patient’s  wrist,  and  bends  the  arm.  At  the  same  time  he  presses 
on  the  radius  and  ulna  with  his  knee,  so  as  to  separate  them  from  the 
os  humeri,  and  thus  the  coronoid  process  is  thrown  from  the  posterior 
fossa  of  the  humerus ; and  whilst  this  pressure  is  supported  by  the 


534 


PARTICULAR  DISLOCATIONS. 


knee,  the  arm  is  to  be  forcibly  but 
slowly  bent,  and  the  reduction  is  soon 
effected.” 

The  same  object  may  be  obtained  by 
bending  the  arm  around  a moderate- 
sized stancheon,  instead  of  the  knee. 
Still  a third  wav  is  sometimes  had 
recourse  to;  the  surgeon  directs  an 
assistant  to  make  extension  from  the 
wrist,  or,  as  Pirrie  advises,  from  the 
middle  of  the  forearm,  drawing  the 
arm  straight,  while  he  with  his  two 
thumbs  presses  the  olecranon  down- 
wards, until  the  coronoid  process  is 
on  a level  with  the  trochlea ; then  he 
presses  it  directly  forwards,  the  assist- 
ant, at  the  same  time,  being  requested 
to  flex  the  forearm. 

When  the  reduction  has  been  suc- 
cessful, the  forearm  can  be  extended 
and  flexed  without  causing  much  pain 
or  resistance;  and  there  is  little  dis- 
position of  the  bones  to  become  re- 
luxated  in  consequence  of  the  pecu- 
liar anatomical  arrangement  of  the 
joint  surfaces.  It  will  be  necessary  to  simply  support  the  forearm  in 
a sling,  and  quell  inflammatory  action  by  the  application  of  cold 
water-dressings  or  other  antiphlogistic  remedies,  to  the  joint ; at  the 
end  of  eight  or  ten  days  commence  passive  motion  to  prevent  anchy- 
losis. 

2.  Dislocation  forwards. — Some  eminent  surgeons,  among  whom  we 
find  Sir  A.  Cooper,  deny  the  possibility  of  this  luxation  without  a 
fracture  of  the  olecranon  process;  but  there  are  now  some  six  well- 
authenticated  cases  upon  record ; so  that  it  must  be  accepted  as  a pos- 
sible accident.  It  is  either  incomplete  or  complete ; in  the  former  case 
the  apex  of  the  olecranon  rests  upon  the  trochlea,  and  in  the  latter,  in 
front  of  this  articular  surface ; usually  the  olecranon  deviates  to  the 
right  or  left. 

Causes.— The  olecranon  is  thrown  in  front  of  the  lower  end  of  the 
humerus,  by  violent  twisting  of  the  forearm  while  the  arm  is  either 
forcibly  extended  or  flexed. 

Symptoms. — I n Velpeau’s  case  the  forearm  was  bent  at  right  angles 
with  the  arm,  and  the  elbow  immovable ; the  rounded  lower  extremity 
of  the  humerus  projected  backwards  in  the  place  of  the  sharp-outlined 
olecranon  ; the  forearm  was  strongly  supinated  and  slightlv  shortened, 
the  olecranon  occupied  a position  upwards  and  outwards,  while  the 
head  of  the  radius  lay  in  the  coronoid  fossa. 

Treatment. — When  the  tip  of  the  olecranon  rests  upon  the  trochlea, 
reduction  may  be  accomplished  by  either  flexing  or  extending  the 
forearm.  In  complete  dislocation,  forced  flexion  is  necessary,  and, 


Fig.  476. 


Reduction  with  the  knee  in  the  bend  of  the 
elbow. 


DISLOCATION  OF  THE  RADIUS  AND  ULNA. 


535 


perhaps,  extension,  from  the  wrist  and  counter-extension  from  the 
lower  third  of  the  arm. 

3.  Dislocation  of  the  Radius  and  Ulna  outwards  (Fig.  477). — This  is 
an  unusual  form  of  injury,  and  is  either  incomplete  or  complete : in  the 
former  instance  the  greater  sigmoid  notch  embraces  the  depression 
separating  the  trochlea  of  the  humerus  from  the  external  condyle,  or 
it  moves  still  further  outwards  and  backwards ; so  that  the  coronoid 
process  rests  upon  the  posterior  surface  of  the  external  condyle,  while 
the  posterior  plane  of  the  olecranon  turns  outwards,  throwing  the 
head  of  the  radius  forwards  (dislocation  backwards 
and  outwards).  In  complete  luxation  both  bones 
abandon  completely  the  posterior  and  inferior  sur- 
faces of  the  humerus,  moving  outwards ; the  radius 
in  most  cases  being  thrown  forwards  or  backwards, 
generally  the  former,  in  consequence  of  the  annu- 
lar ligament  being  ruptured. 

In  these  cases  the  lateral  ligaments  are  severely 
stretched,  and,  in  complete  luxation,  ruptured;  the 
fibres  of  the  brachialis  anticus  and  anconeus  mus- 
cles suffer  in  a similar  manner. 

Causes. — The  injury  results  from  blows  near  the 
elbow  upon  the  inner  side  of  the  forearm,  or  outer 
side  of  the  arm ; or  from  two  forces  operating 
upon  these  points  in  opposite  directions ; from  falls 
upon  the  elbow  or  hands  in  the  efforts  of  a person 
to  prevent  his  body  striking  the  ground;  and 
from  violently  twisting  the  forearm. 

Symptoms. — The  elbow  is  increased  in  breadth, 
and  there  will  be  a notable  prominence  of  the  head 
of  the  radius  upon  its  outer  border,  and  a corres- 
ponding depression  upon  its  inner  border  beneath 
the  internal  condyle ; when  the  coronoid  process  incomplete  dislocation 
is  behind  the  condyle,  the  olecranon  projects  pos-  outwards, 

teriorly  and  is  above  a horizontal  line  passing 
between  the  condyles;  the  motions  of  the  elbow-joint  are  nearly 
abolished ; the  forearm  is  flexed  upon  the  arm  at  an  angle  of  about 
135  degrees  and  strongly  pronated,  and  appears  to  be  twisted  upon 
its  axis ; so  that  its  inner  surface  looks  posteriorly  and  the  posterior 
surface  outwards. 

Prognosis. — The  prognosis  is  of  the  same  character  as  when  the 
bones  are  dislocated  posteriorly. 

Treatment. — When  the  ulna  takes  a position  behind  the  external 
condyle,  the  same  manoeuvres  will  be  required  as  those  described  for 
posterior  luxation.  In  complete  dislocation,  extension  from  the  hand 
and  counter-extension  from  the  lower  part  of  the  humerus  will  be 
required,  while  the  surgeon  presses  the  bones  with  his  fingers  in 
opposite  directions  to  their  displacement.  When  the  head  of  the 
radius  is  thrown  forward  upon  the  ulna,  the  forearm  must  be  supinated 
before  the  extension  is  made. 

4.  Dislocation  of  the  Radius  and  Ulna  inwards  (Fig.  47 8). — This  is  a still 


Fig.  477. 


536 


PARTICULAR  DISLOCATIONS. 


Fig.  478. 


rarer  form  of  dislocation  than  the  preceding,  a fact  depending,  doubtless, 
upon  the  shape  of  the  joint-surfaces — the  trochlea  sloping  from  within 
outwards  offers  more  resistance  to  a torce  tending  to  drive  the  ulna 
towards  the  inner  condyle.  It  may  also  be  incomplete  or  complete; 

in  the  former  variety,  the  sigmoid  cavity  embraces 
the  inner  condyle,  and  the  head  of  the  radius  is 
drawn  inwards  beneath  the  trochlea,  or  the  coronoid 
process  moves  back  behind  the  inner  condyle,  and 
the  head  of  the  radius  reposes  in  the  olecranon  fossa, 
as  happens  in  some  cases.  In  complete  luxation, 
the  bones  are  entirely  separated  from  the  lower  and 
posterior  surfaces  of  the  lower  end  of  the  humerus. 

The  lateral  ligaments  are  stretched  or  torn,  and 
the  fibres  of  the  anconeus  and  tibialis  anticus  suffer 
more  or  less  in  the  same  manner.  From  the  position 
of  the  olecranon  over  the  course  of  the  ulnar  nerve 
this  may  be  pressed  upon  or  even  crushed. 

Symptoms. — -The  arm  is  bent,  and  the  forearm 
generally  strongly  pronated ; the  external  condyle 
is  prominent ; and  from  the  absence  of  the  head  of 
the  radius,  a depression  will  be  found  below  it ; the 
head  of  the  radius  commonly  remains  beneath  the 
trochlea,  though  it  will  sometimes  form  a tumor  by 
projecting  anteriorly  in  the  bend  of  the  elbow. 
The  olecranon  forms  a prominence  upon  the  inner 
side  of  the  arm  in  the  position  of  the  epicondyle ; 
if  the  coronoid  process  is  behind  the  inner  condyle, 
the  forearm  will  be  shortened.  The  prognosis  and 
treatment  are  the  same  as  for  dislocation  outwards. 

5.  Dislocation  of  the  Radius  forwards,  and  the  Ulna  backwards. — 
Three  cases  of  this  injury  are  recorded,  and  from  them  it  may  be 
gathered  that  the  symptoms  characterizing  this  luxation  are  a com- 
bination of  those  presented  by  dislocation  of  the  radius  and  ulna 
separately,  and  that  the  treatment  must,be  conducted  upon  the  prin- 
ciples applicable  to  them. 

II.  Dislocation  of  the  Radius.  1.  Dislocation  of  the  Radius 
backwards. — This  is  the  most  common  form  of  the  dislocations  of  the 
radius,  and  is  not  unfrequently  associated  with  fracture  of  the  con- 
dyles or  of  the  upper  end  of  the  radius. 

The  head  of  the  radius,  rupturing  the  annular,  oblique,  and  capsu- 
lar ligaments,  escapes  from  the  lesser  sigmoid  notch,  and  takes  up  a 
position  behind  and  to  the  external  side  of  the  outer  condyle. 

Causes. — The  causes  are  falls  upon  the  palms  of  the  hands,  while 
the  forearm  is  strongly  pronated ; raising  persons  from  the  ground  by 
the  hand,  particularly  children;  and  finally,  direct  blows  upon  the 
front  and  outer  margin  of  the  forearm. 

Symptoms. — The  forearm  is  semiflexed  and  pronated;  supination  is 
impossible;  flexion  and  extension  limited  and  painful;  the  natural 
convex  outline  of  the  outer  margin  of  the  forearm  is  flattened;  the 


Incomplete  dislocation 
inwards. 


DISLOCATION  OF  THE  RADIUS. 


537 


biceps  tendon  is  tense;  and  the  bead  of  tbe  humerus  can  be  felt 
behind  the  outer  condyle,  beneath  which  there  is  a marked  depression. 

Treatment. — Make  extension  from  the  wrist,  and  counter-extension 
from  the  arm  ; then  forcibly  supinate  the  forearm;  the  reduction  may 
be  facilitated  by  making  pressure  upon  the  head  of  the  radius  from 
behind  forwards  with  the  thumbs.  When  the  bone  is  restored  to  its 
natural  position,  the  arm  may  be  kept  in  a straight  posture,  the 
tendon  of  the  biceps  will  thus  be  made  to  aid  in  maintaining  the 
reduction;  passive  motion  must  be  instituted  in  eight  or  ten  days. 

If  accompanied  with  fracture  of  the  inner  condyle,  Markoe  recom- 
mends the  arm  to  be  supported  by  a splint,  in  a position  about  ten 
degrees  less  than  a right  angle. 

2.  Dislocation  of  the  Radius  forwards  (Fig.  479). — In  this  luxation  the 
head  of  the  radius  is  thrown  forwards  upon  the  humerus;  the  an- 
terior lateral  and  annular  ligaments 
are  more  or  less  torn,  though  in 
some  cases  the  latter  may  be  only 
stretched.  The  dislocation  is  either 
incomplete  or  complete.  Gloyrand 
(Annales  de  la  Chirurgie  Francaise, 

1842,  vol.  v.  p.  129)  describes  the 
former  as  a slight  displacement  of 
the  head  of  the  radius  forwards, 
occurring  in  children  from  being 
lifted  from  the  ground  by  their 
hands,  or  being  held  by  the  hand 
when  they  stumble  and  fall. 

Causes.- — The  causes  are,  falls 
upon  the  palms  of  the  hands,  vio- 
lent pronation  of  the  forearm,  a 
direct  blow  upon  the  upper  and 
posterior  part  of  the  radius. 

Symptoms. — When  a child  suf- 
fers from  an  incomplete  luxation, 
it  cries  out  immediately  with  pain 
of  the  arm,  which  is  slightly  bent 
and  the  forearm  pronated ; supina- 
tion being  impossible  or  extremely 
difficult ; and  the  elbow  is  not 
swollen.  In  complete  dislocation  the  head  of  the  radius  will  be  felt 
in  the  fold  of  the  arm ; there  will  be  a depression  beneath  the  exter- 
nal condyle;  the  curved  outline  of  the  radial  border  of  the  forearm 
will  be  flattened.  Delpech  states  that  the  forearm  will  be  generally 
found  supinated;  while  Malgaigne  and  other  surgeons  regard  pronation 
as  the  characteristic  position.  Certain  cases  have  also  been  observed 
where  the  forearm  was  midway  between  pronation  and  supination; 
the  arm  is  slightly  bent,  the  tendon  of  the  biceps  relaxed,  and  flexion 
of  the  forearm  beyond  a right  angle  impossible. 

Treatment. — Goyrand  advises  that  extension  should  be  made  from  the 
wrist  with  the  surgeon’s  right  hand,  and  counter-extension  with  the  left, 


Fig.  479. 


538 


PARTICULAR  DISLOCATIONS. 


Fl--  480-  upon  the  lower  part  of  the  humerus, 

the  thumb  of  this  hand  being  placed 
upon  the  head  of  the  radius.  While 
extension  is  being  made,  supinate 
the  forearm;  then  suddenly  flex  it 
as  much  as  possible,  the  thumb 
pressing  strongly  outwards  upon  the 
radius  all  the  time.  Assistants  may 
make  the  extension  and  counter- 
extension while  the  surgeon  presses 
the  head  of  the  radius  backwards 
with  his  thumb.  Sir  A.  Cooper  di- 
rects the  arm  to  be  supinated,  while 
Denucd  recommends  the  prone  pos- 
ture during  extension. 

The  dislocation  is  apt  to  be  repro- 
duced when  the  forearm  is  extended, 
and  it  will  be  advisable,  therefore, 
to  place  the  arm  in  an  angular  splint, 
with  a compress  over  the  head  of  the 
radius. 

3.  Dislocation  of  the  Radius  out- 
wards.— This  is  sometimes  a primary 
luxation,  but  more  commonly  conse- 
cutive to  either  the  anterior  or  pos- 
terior dislocations. 

Symptoms. — The  head  of  the  ra- 
dius forms  a prominence  outside  of 
the  epicondyle,  giving  a greater  width,  as  well  as  a greater  convexity 
to  the  upper  part  of  the  forearm,  which  is  in  a position  midway 
between  supination  and  pronation;  complete  supination  being  impos- 
sible, though  extension  and  flexion  can  be  performed. 

Treatment. — The  reduction  may  be  effected  by  bending  the  arm  at 
right  angles,  and  making  extension  and  counter-extension  from  the 
wrist  and  lower  part  of  the  arm ; at  the  same  moment  the  surgeon 
will  press  with  his  thumb  the  head  of  the  radius  downwards  and  in- 
wards, to  its  normal  position  beneath  the  condyle  of  the  humerus. 

The  bone  is  liable  to  slip  out  of  position  again  in  the  movements  of 
the  forearm ; and  it  will  be  necessary,  in  order  to  counteract  this,  to 
keep  the  arm  in  a flexed  position,  with  a compress  upon  the  outer  side 
of  the  elbow  by  an  angular  splint,  with  bandages. 

III.  Dislocations  of  the  Ulna.  a.  Dislocation  of  the  Upper  Ex- 
tremity of  the  Ulna. — Dislocation  of  the  ulna  backwards  may  occur, 
though  it  is  rare,  and  usually  accompanied  with  fracture  of  the  outer 
condyle  of  the  humerus,  or  fracture  of  the  neck  of  the  radius. 

Malgaigne  states  that  the  only  peculiarity  of  this  luxation  is,  that 
the  head  of  the  radius  can  be  felt  in  its  natural  position,  the  other 
symptoms  being  the  same  as  those  of  dislocation  of  both  bones  back- 
wards. The  reduction  is  also  accomplished  in  the  same  manner  as 
directed  for  this  luxation. 


External  appearance  of  a dislocation  of  the 
radius  forwards. 


DISLOCATION  OF  CARPUS  UPON  RADIUS  AND  ULNA.  539 

b.  Dislocation  of  the  Lower  Extremity  of  the  Ulna.  1.  Dislocation 
of  the  lower  end  of  the  Ulna : forwards. — In  this  form  of  luxation  the 
stylo-pisiform  and  capsular  ligaments  are  torn,  and  the  lower  end  of 
: the  ulna  is  thrown  in  front  of  the  radius. 

Causes. — Forced  supination  of  the  forearm. 

Symptoms. — The  arm  is  slightly  bent ; the  forearm  supinated  ; and 
the  hand  inclined  to  its  radial  border ; the  fingers  are  semi-flexed ; 
there  is  a depression  upon  the  inner  side  of  the  forearm  above  the 
wrist,  caused  by  the  ulna  sloping  across  the  lower  part  of  the  radius ; 
the  styloid  process  can  no  longer  be  felt  in  its  prominent  position  upon 
the  inner  border  of  the  wrist,  which  is  diminished  in  width,  and 
rounded ; and  lastly,  the  point  of  the  ulna  forms  a tumor  in  front  of 
the  radius. 

Treatment. — The  hone  may  he  restored  to  its  natural  position  in  the 
following  manner : The  surgeon  seizes  the  forearm  in  both  his  hands, 
with  the  thumbs  placed  between  the  bones,  and  the  fingers  steadying 
; the  radius;  and  while  an  assistant  pronates  the  forearm  he  shoves  the 
ulna  in  position  with  his  thumb.  If  there  is  any  disposition  of  the 
ulna  to  become  reluxated,  two  padded  splints  may  be  confined  to  the 
forearm  with  a roller  bandage. 

2.  Dislocation  of  the  Lower  End  of  the  Ulna  backwards. — This  is 
exactly  the  reverse  of  the  preceding  luxation  ; the  distal  extremity  of 
the  ulna  is  thrown  upon  the  posterior  surface  of  the  radius. 

Causes. — It  is  caused  by  violent  pronation  of  the  forearm. 

Treatment. — The  arm  will  be  found  slightly  bent,  and  the  forearm 
pronated;  the  hand  and  fingers  are  semi-flexed;  the  point  of  the  ulna 
forms  a tumor  on  the  back  of  the  wrist,  wdiich  is  diminished  in  width 
by  the  overlapping  of  the  two  bones  below. 

Treatment. — The  same  manipulation  may  be  employed  in  this  case 
as  in  dislocation  forwards,  with  this  difference,  that  as  the  surgeon 
presses  the  ulna  inwards  with  his  thumbs,  the  assistant  must  supinate 
the  forearm. 

Dislocation  of  the  Carpus  upon  the  Radius  and  Ulna. 

Dislocation  of  the  Carpus — 

1.  Backwards. 

2.  Forwards. 

1.  Dislocation  of  the  Carpus  backwards  (Fig.  481). — The  causes  of  this 
injury  are  direct  violence  inflicted  upon  the  wrist,  driving  the  carpus 
backwards,  and  falls  upon  the  hands  in  a flexed  position.  The  carpus  is 
forced  upon  the  posterior  surface  of  the  radius  under  the  extensor  ten- 
dons, which  are  stretched  over  its  upper  extremity ; the  ligaments  of 
the  wrist-joint  are  more  or  less  torn ; and  the  arteries,  nerves,  and 
muscles  in  the  neighborhood  bruised.  The  dislocation  is  sometimes 
compound,  and  at  others  complicated,  with  a fracture  of  the  lower 
end  of  the  radius  or  ulna. 

Symptoms.  — The  forearm  is  shortened  when  measured  from  the 
olecranon  to  the  tip  of  the  middle  finger,  while  the  distance  between 
1 the  former  point  and  the  styloid  process  remains  unchanged ; there  is 
a large  prominence  formed  by  the  carpus  upon  the  back  of  the  fore- 


540 


PARTICULAR  DISLOCATIONS. 


arm,  and  another  in  front,  caused  by 
the  lower  projecting  ends  of  radius 
and  ulna,  below  which  there  is  a 
well-marked  depression;  the  sty- 
loid processes  are  not  in  the  same 
line  as  the  carpal  bones ; the  wrist  is 
much  thicker  than  natural,  and  the 
fingers  are  semi-flexed. 

Treatment.  — Compound  disloca- 
tion of  the  wrist  often  requires  amputation  or  resection ; but  perfect 
rest,  cooling  lotions,  and  other  antiphlogistic  remedies  will  accom- 
plish much  in  some  of  these  cases  in  securing  a favorable  issue  with- 
out operation ; though  anchylosis  and  excessive  inflammation  with 
profuse  suppuration  are  at  all  times  to  be  feared. 

The  carpus  may  be  restored  to  its  articular  relation  by  directing  an 
assistant  to  make  counter-extension  from  the  forearm,  while  another 
grasps  the  metacarpus  and  effects  extension ; the  surgeon  then  en- 
deavors to  push  the  carpus  downwards  with  his  thumbs. 

Malgaigne  states  that  in  the  above  plan  the  hold  upon  the  meta- 
carpus is  not  sufficiently  firm,  at  the  same  time  it  puts  the  skin  on  the 
stretch  and  opposes  in  some  measure  the  reduction.  His  method  is  to 
make  the  extension  by  grasping  the  last  four  fingers,  and  with  a lac 
fastened  around  the  metacarpus  above  the  roots  of  the  fingers. 

2.  Dislocation  of  the  Carpus  for- 
wards (Fig.  482). — In  this  variety 
of  dislocation  the  carpus  is  thrown 
forwards  upon  the  anterior  face  of 
the  radius. 

The  causes,  symptoms,  and 
treatment  are  the  reverse  of  those 
of  dislocation  backwards. 

Dislocation  of  the  Carpal  Bones  upon  each  other. 

The  carpal  bones  are  so  strongly  bound  together  by  ligaments,  and 
protected  by  the  tendons  crossing  them  at  the  wrist,  as  well  as  possess- 
ing such  a limited  range  of  motion,  that  a simple  dislocation  is  rather 
of  an  uncommon  occurrence. 

The  os  magnum  is  thrown  backwards  by  falls  upon  the  back  of  the 
hand,  violently  flexing  it.  I saw  a case  of  a young  lady  who  fell  from 
her  horse  upon  the  hand.  A tumor  was  observed  upon  its  back,  which 
could  be  made  to  disappear  by  firm  pressure  upon  it,  but  returned 
immediately  when  the  hand  was  flexed ; a compress  was  placed  over 
the  os  magnum,  and  two  straight  splints  upon  the  forearm  secured  by 
a roller  bandage ; after  the  treatment  the  wrist  remained  iveak  for 
several  months,  and  there  was  a slight  prominence  at  the  seat  of  the 
injury. 

Should  simple  pressure  not  suffice  to  reduce  the  bone,  extension 
should  ffie  made  at  the  same  time  from  the  index  and  middle  fingers. 

Sir  A.  Cooper  states  that  both  the  os  magnum  and  cuneiform  may 


Fig.  482. 


Dislocation  of  the  carpus  forwards. 


Fig.  481. 


DISLOCATION  OP  THE  METACARPUS. 


541 


be  displaced  backwards  from  relaxation  of  tbe  ligaments  ; and  in  the 
case  of  a young  lady  in  whom  it  occurred,  she  was  compelled  to  wear 
two  short  splints  to  strengthen  the  wrist;  for  the  same  purpose  another 
lady  wore  a broad  steel-chain  bracelet  clasping  the  wrist  tightly. 

Mr.  Erichsen  saw  the  case  of  a patient  who  fell  from  a height, 
injuring  the  spine  and  doubling  the  right  hand  under  him.  “ On 
examining  the  wrist,  a small  hard  tumor  was  felt  projecting  on  its 
dorsal  aspect,  which  usually  disappeared  on  extending  the  hand  and 
employing  firm  pressure,  but  started  up  again  so  soon  as  the  wrist 
was  forcibly  flexed.  It  was  evident  that  this  bone  belonged  to  the 
first  row  of  the  carpus,  articulating  with  the  radius;  and  from  its  size, 
Its  position  towards  the  radial  side  of  the  carpus,  and  its  shape,  which 
could  be  distinctly  made  out  through  the  integuments,  there  could  be 
little  doubt  that  it  was  the  semilunar  bone.” 

Fergusson  says : “ I have  known  of  one  example  in  which  the  pisi- 
form bone  was  detached  from  its  lower  connections  by  the  action  of 
the  flexor  carpi-ulnaris.  Little  benefit  can  be  expected  from  any 
attempt  to  keep  this  bone  in  its  proper  position,  nor,  indeed,  is  the 
displacement  of  much  consequence.” 

South  states  that  the  unciform  is  sometimes  thrown  backwards  by 
the  relaxation  of  the  ligaments,  and  forms  a projection  on  the  back  of 
the  hand  when  it  is  flexed.  The  hand  cannot  be  used  without  the 
wrist  is  supported,  and  be  directs  for  this  purpose  the  application  of 
■strips  of  adhesive  plaster  and  a bandage. 

Dislocation  of  the  Metacarpus. 

The  limited  amount  of  motion  enjoyed  by  the  metacarpal  bones, 
their  arrangement  in  a parallel  row  with  their  proximal  extremities 
supporting  each  other  like  wedges,  and  bound  together  by  strong 
ligamentous  fasciculi  passing  between  them  and  the  carpus,  render 
dislocation  at  the  carpo- metacarpal  articulation  uncommon. 

The  first  metacarpal  bone,  from  its  exposed  position  upon  the  outer 
border  of  the  hand,  and  the  greater  extent  of  motion  possessed-  by  it, 
is  more  frequently  dislocated  than  any  of  the  others. 

The  luxation  may  occur  backwards,  or  forwards  and  inwards. 

1.  Dislocation  of  the  First  Metacarpal  Bone  backwards. — This  injury 
is  caused  by  a force  applied  to  its  lower  extremity,  forcing  it  upwards 
;,and  generally  throwing  the  thumb  into  forced  flexion ; it  has  also  been 
produced  by  violence  acting  upon  the  anterior  aspect  of  the  bone. 

The  ligaments  surrounding  the  joint  are  more  or  less  ruptured,  and 
the  proximal  extremity  of  the  bone  is  thrown  upon  the  posterior 
surface  of  the  trapezium. 

Symptoms. — There  is  a protuberance  formed  by  the  end  of  the  bone 
upon  the  back  of  the  hand ; the  thumb  is  generally  flexed  and  in- 
clined across  the  palm  of  the  hand,  and  its  motions  abolished. 

Treatment. — The  reduction  is  accomplished  by  making  extension 
and  counter-extension,  and  at  the  same  time  pressure  downwards  upon 
the  displaced  bone ; then  apply  a narrow  splint,  with  a compress  over 
the  joint,  upon  the  outer  margin  of  the  hand  and  wrist,  if  there  is  any 
tendency  to  reluxation. 


542 


PARTICULAR  DISLOCATION'S. 


2.  Dislocation  of  the  First  Metacarpal  Bone  forwards  and  inwards. — 
Here  the  proximal  end  of  the  bone  lies  in  front  of  the  carpus  between 
the  trapezium  and  the  root  of  the  second  metacarpal  bone. 

Symptoms. — A tumor  is  formed  in  front  towards  the  palm  of  the 
hand ; the  thumb  is  thrown  outwards,  and  its  tip  cannot  be  brought  in 
contact  with  the  point  of  the  little  finger,  nor  can  it  be  adducted. 

The  reduction  may  be  attempted  by  making  extension  and  gradu- 
ally carrying  the  thumb  towards  the  palm  of  the  hand;  pressure  out- 
wards upon  the  root  of  the  bone  may  be  made  at  the  same  time. 

3.  Dislocation  of  the  Outer  Four  Metacarpal  Bones.— 'Si.  Bourguet 
has  reported  a case  of  luxation  of  the  second  metacarpal  bone  for- 
wards, and  Blaudin  and  Roux,  each,  one  of  the  third  metacarpal  bone 
backwards. 

Dr.  Hamilton  relates  two  cases  of  an  incomplete  posterior  luxation 
of  the  second  and  third  metacarpal  bones  at  the  same  time  by  the 
patient’s  striking  a blow  with  the  clenched  fist. 

The  symptoms  are  pain,  swelling,  and  deformity  over  the  carpo- 
metacarpal articulation. 

Treatment. — Extension  from  the  finger  of  the  displaced  metacarpal 
bone,  combined  with  pressure  upon  its  proximal  extremity. 

Should  there  be  any  disposition  to  a recurrence  of  the  displacement, 
a straight  splint  with  the  necessary  compresses  should  be  applied  to 
the  hand. 


Dislocation  of  the  Phalanges. 

A.  Dislocation  of  the  First  Row  of  Phalanges. — Dislocation 
of  the  first  phalanx  of  the  thumb  is  more  frequent  than  any  other, 
and  may  be  complete  or  incomplete.  It  occurs  backwards  or  forwards. 

1.  Dislocation  of  the  First  Phalanx  of  the  Thumb  backwards.— This 
happens  more  frequently  than  in  a forward  direction.  It  is  caused  by 
any  force  doubling  the  thumb  back  upon  the  baud.  "When  the  luxa- 
tion is  complete,  the  proximal  end  of  the  first  phalanx  takes  a position 
behind  the  adjoining  extremity  of  the  metacarpal  bone  and  at  right 
angles  with  it,  while  the  second  phalanx  is  flexed  and  forms  an  angle 
with  the  first,  so  that  the  shape  of  the  thumb  will  represent  some- 
what the  letter  Z,  as  seen  in  Fig.  483  ; the  distal 
end  of  the  first  metacarpal  bone  forms  a tumor  in 
front  of  the  thumb  looking  towards  the  palm. 
Sometimes,  however,  the  first  phalanx  and  the 
metacarpal  bone  lie  in  parallel  positions,  and  this 
characteristic  shape  of  the  thumb  will  not  be  seen, 
and  the  tumor  spoken  of  above  as  looking  to- 
wards the  palm  will  then  present  itself  upon  the 
posterior  aspect  of  the  thumb. 

Symptoms. — These  changes  of  outliue  of  the 
thumb,  with  abolition  of  its  functions,  will  render 
the  identification  of  the  injury  easy. 

Prognosis. — The  reduction  of  this  dislocation 
in  recent  cases  is  sometimes  effected  with  ease: 
but  there  are  cases  in  which  great  difficulty  will 


Fig.  483. 


wards. 


DISLOCATION  OF  THE  PHALANGES. 


543 


be  encountered  from  some  peculiarity  in  the  nature  of  the  injury, 
which  has  not  as  yet  been  certainly  and  satisfactorily  explained. 
Some  surgeons  attribute  it  to  the  rupture  and  interposition  of  the 
anterior  ligament  between  the  joint-surfaces ; Hey  to  the  lifting  of 
the  lateral  ligaments  over  the  end  of  the  metacarpal  bone  which  is 
constricted  by  them,  and  some  again  charge  the  difficulty  to  the  mus- 
cles; Vidal  de  Cassis  says  the  distal  extremity  of  the  metacarpal  bone 
j is  constricted  between  the  two  heads  of  the  short  flexor  of  the  thumb  ; 
there  are  others  who  think  that  the  bones  are  at  fault,  and  that  the 
obstacle  to  reduction  is  the  interlocking  of  the  margins  of  their 
articular  surfaces. 

Treatment. — There  are  various  methods  recommended  for  the  re- 
duction of  this  dislocation;  some  consisting  in  simple  manipulation 
with  the  fingers,  and  others  in  the  application  of  apparatus  for 
extension. 

In  the  ordinary  process  by  manipulation  the  surgeon  presses  the 
distal  extremity  of  the  first  phalanx  upwards  so  as  to  throw  its  articu- 
lating surface  in  the  direction  of  the  farther  end  of  the  metacarpal 
bone ; then  supporting  the  phalanx  in  this  position  with  the  fingers, 
and  pressing  against  the  distal  end  of  the  metacarpal  bone,  the  thumbs 
are  forcibly  pressed  against  the  base  of  the  displaced  phalanx  to  throw 
it  into  its  natural  position.  Dr.  Batchelder,  of  New  York,  has  im- 
proved this  method  in  some  particulars  worthy  of  special  notice.  He 
directs  the  surgeon  “to  take  the  metacarpal  portion  of  the  dislocated 
thumb  between  the  thumb  and  finger  of  one  hand,  and  flex,  or  force 
it,  as  far  as  may  be,  into  the  palm  of  the  hand,  for  the  purpose  of  re- 
laxing the  muscles  connected  with  the  proximal  end  of  the  phalanx, 
particularly  the  flexor  brevis  pollicis.  He  should  then  apply  the  end 
of  the  thumb  of  this  hand  against  the  displaced  extremity  of  the  dis- 
located phalanx  for  the  purpose  of  forcing  it  downwards,  and  at  the 
same  time  grasp  the  displaced  thumb  with  his  other  hand,  and  move 
it  forcibly  backwards  and  forwards,  as  in  strongly  forced  flexion  and 
: extension,  the  pressure  against  the  upper  extremity  of  the  first 
phalanx  being  kept  up.  In  this  way  the  dislocated  bone  may  be 
made  to  descend,  so  as  to  be  almost  or  quite  on  a line  with  the 
articulating  surface  of  the  metacarpal  bone,  when  the  thumb  may  be 
forcibly  flexed ; and,  if  it  be  not  reduced,  is  forcibly  extended,  and 
brought  backwards  to  a right  angle  with  the  metacarpal  bone ; when, 
if  the  downward  pressure  with  the  thumb,  placed  as  before  directed 
for  that  purpose,  has  been  continued  (which  thumb,  by  maintaining 
i its  position,  acts  as  a fulcrum,  as  well  as  by  its  pressure),  the  bone  will 
slip  into  its  place,  and  the  reduction  be  effected.” 

Should  these  manipulations  not  succeed,  extension  may  be  had 
recourse  to  (Fig.  484).  For  this  purpose,  Sir  A.  Cooper  recommended 
that  the  thumb  be  adducted,  to  relax  the  muscles  connected  with  the 
proximal  extremity  of  the  phalanx;  a piece  of  soft  leather  was  wrapped 
' around  this  phalanx,  and  over  this  a lac  is  fastened  by  the  clove-hitch ; 
the  surgeon,  grasping  the  ends  of  the  lac,  will  be  enabled  to  make  the 
required  amount  of  traction,  while  an  assistant  seizes  the  hand  of  the 
patient  with  his  fingers  placed  between  the  thumb  and  radial  border 


544 


PARTICULAR  DISLOCATION'S. 


of  the  palm,  and  makes  the  counter-extension ; or  some  wool  may  he 
put  between  the  finger  and  thumb,  and  a counter-extending  band  be 
used. 

Another  plan  of  this  surgeon  was  to  attach  a weight  to  the  lac 
running  over  a pulley. 


Fig.  484. 


Sir  A.  Cooper’s  method  of  makiDg  extension  with  a weight  in  dislocation  of  the  thumb. 

A much  more  efficient  way  of  making  extension  and  of  getting 
complete  command  over  the  thumb  is  with  a very  simple  instrument 
contrived  by  Dr.  Levis,  of  Philadelphia.  It  consists  of  “a  thin  strip 
of  hard  wood,  about  ten  inches  in  length,  and  one  inch,  or  rather  more, 
in  width.  One  end  of  the  piece  is  perforated  with  six  or  eight  holes. 


Fig.  485. 


The  opposite  end  is  partly  cut  away,  forming  a projecting  pin,  and 
leaving  a shoulder  on  each  side  of  it.  Towards  this  end  of  the  strip 
a sort  of  handle  shape  is  given  to  it,  so  as  to  insure  a secure  grasp  to 
the  operator.  Two  pieces  of  strong  tape  or  other  material,  about  one 
yard  in  length,  are  prepared.  One  of  these  is  passed  through  tlie 
holes  at  the  end  of  the  strip,  leaving  a loop  on  one  side.  The  other 
tape  is  passed  through  another  pair  of  holes,  according  as  it  may  be 


Fig.  4S6. 


a thumb  or  finger  to  which  it  is  to  be  applied,  or  varied  to  suit  the 
length  of  the  finger,  leaving  a similar  loop.  If  a dislocated  thumb  is 
to  be  acted  on,  the  second  tapes  should  be  passed  through  the  holes 
nearest  the  first.  The  ends  of  each  separate  tape  are  then  tied  to- 
gether.” 


DISLOCATION  OF  THE  PHALANGES. 


545 


He  directs  the  apparatus  to  be  applied  “by  passing  the  finger 
through  the  loops.  The  loop  nearest  the  first  joint  is  then  tightened 
by  drawing  on  the  tape,  which  is  then  brought  along  the  strip  to  the 
opposite  end,  across  one  of  the  shoulders,  and  secured  by  winding  it 
firmly  around  the  projecting  pin.  The  other  tape  is  tightened  in  a 
like  manner,  crossing  the  other  shoulder,  and  winding  around  the  pin 
in  an  opposite  direction;  when,  for  security,  the  ends  of  the  tapes  are 
finally  tied  together.” 

The  same  end,  that  of  securing  complete  control  over  the  motions 
of  the  thumb,  was  kept  in  view  by  Luer,  of  Paris,  in  constructing  his 
forceps  for  the  reduction  of  dislocated  phalanges.  The  points  of  the 
forceps  are  bifurcated;  between  each  pair  of  which  a piece  of  strong 
cloth  or  canvas  is  stretched,  to  grasp  the  thumb  firmly;  additional 
power  may  be  gained  by  placing  inside  of  the  canvas  two  pieces  of 
cork  or  caoutchouc. 

Charri5re,  of  the  same  city,  contrived  a pair  of  forceps  for  the  same 
purpose ; they  were  articulated  at  one  extremity,  in  the  same  manner 
as  an  ordinary  pair  of  dividers,  and  divided  at  the  other  into  four 
prongs,  to  which  four  leather  straps  are  attached  in  such  a manner  as 
to  make  two  slip-knots,  in  which  the  thumb  is  to  be  placed,  and  held 
firmly  by  pressing  upon  the  forceps. 

Hr.  Hamilton  suggested  the  employment  of  a toy  called  the  “ Indian 
puzzle,”  for  making  extension  upon  dislocated  fingers.  It  “is  an  elon- 
gated cone  of  about  sixteen  or  eighteen  inches  in  length,  made  of  ash 
splittings,  and  braided ; the  open  end  of  the  cone  being  about  three- 


Fig.  437. 


“Indian  puzzle,”  employed  for  the  reduction  of  dislocations  of  the  phalanges. 


fourths  of  an  inch  in  diameter,  and  the  opposite  end  terminating  in 
a braided  cord.  When  applied  to  the  finger,  it  is  slipped  on  lightly, 
forming  a cap  to  the  extremity,  and  to  half  the  length  of  the  finger ; 
but  on  traction  being  made  from  the  opposite  end  it  fastens  itself  to 
the  limb  with  a most  uncompromising  grasp.” 

With  a view  of  making  extension,  and  at  the  same  time  of  flexing 
and  extending  the  thumb  Vidal  de  Cassis  employed  a common  door 
key.  He  placed  the  ring  over  the  dislocated  thumb  so  that  its  palmar 
surface  reposed  upon  the  stem  of  the  key,  while  that  part  of  the  cir- 
cumference of  the  ring  opposite  the  stem  rested  against  the  dorsal  face 
of  the  proximal  extremity  of  the  first  phalanx.  Seizing  the  key  in  the 
right  hand,  the  thumb  is  forced  into  a position  of  dorsal  flexion,  at  the 
same  time  sliding  the  articular  surface  of  the  phalanx  in  the  direction 
of  the  articular  surface  of  the  metacarpal  bone,  when  sudden  flexion 
of  the  thumb  will  replace  the  bone  in  its  natural  position. 

Lastly,  Malgaigne  and  Blandin  have  employed,  in  obstinate  cases,  a 

35 


546 


PARTICULAR  DISLOCATIONS. 


sharp-pointed  metallic  stem,  Avhich  they  forced  through  the  skin  be- 
tween the  articular  surfaces  of  the  phalanx  and  metacarpal  bone,  and 
prized  the  former  into  its  natural  position. 

In  some  of  these  cases,  which  resist  all  the  efforts  of  the  surgeon  at 
reduction,  the  subcutaneous  division  of  the  lateral  ligaments  is 
required. 

When  the  bone  has  been  restored  to  its  natural  articular  connec- 
tions, inflammatory  action  should  be  combated  by  appropriate  anti- 
phlogistic measures ; and,  to  prevent  the  luxation  recurring,  a splint 
may  be  applied,  and  secured  to  the  parts  by  the  spica  of  the  thumb. 

2.  Dislocation  of  the  First  Phalanx  of  the  Thumb  forwards. — This 
form  of  dislocation  is  rare,  and  but  few  cases  are  recorded.  It  is  caused 


Fig.  488. 


Dislocation  of  the  first  phalanx  forwards. 


by  blows  upon  the  back  of  the  phalanx,  the  proximal  extremity,  of 
which  is  driven  in  front  of  the  metacarpal  bone,  forming  a prominence 
in  front.  The  phalanx  and  metacarpal  bone  are  usually  in  parallel 
positions. 

Treatment. — The  reduction  is  effected  by  seizing  the  thumb  in  the 
palm  of  the  right  hand  and  making  extension,  while  the  thumb  of  this 
hand  makes  counter-pressure  upon  the  head  of  the  metacarpal  bone. 
If  this  plan  fails,  the  phalanx  should  be  flexed  firmly  towards  the 
palm.  In  the  cases  reported  no  difficulties  have  been  encountered  in 
the  reduction. 

8.  Dislocation  of  the  First  Phalanges  of  the  Fingers. — Dislocation  of 
the  first  phalanges  of  the  fingers  is  an  uncommon  injury.  It  may 
occur  forwards  or  backwards,  and  be  complete  or  incomplete. 

It  is  caused  by  blows  upon  the  ends  of  the  fingers,  and  is  readily 


Fig.  489. 


Reduction  of  dislocation  of  the  phalanx  backwards  by  extension. 


recognized  by  the  deformity  produced  at  the  metacarpo-phalangeal 
articulation. 

Treatment. — Extension  from  the  finger  will  effect  the  reduction,  as 


DISLOCATION  OP  THE  PELVIC  BONES. 


547 


seen  in  Fig.  489 ; or  forced  flexion  in  forward  luxation,  and  the 
reverse  in  backward  luxation  will  also  be  found  efficient. 

B.  Dislocation  op  the  Second  and  Third  Rows  of  the  Pha- 
langes.— The  phalanges  of  the  second  and  third  rows  of  the  fingers 

Fig.  490. 


Dislocation  of  the  second  phalanx  backwards. 

and  thumb  may  be  dislocated  forwards  or  backwards.  It  is  caused  by 
blows  upon  the  tips  of  the  fingers,  and  is  easily  recognized  by  the 
deformity  of  the  phalangeal  joints. 

The  treatment  is  the  same  as  for  dislocation  of  the  first  phalanges. 

SECTION  III. 

dislocations  of  the  lower  extremities. 

Dislocation  of  the  Pelvic  Bones. 

From  the  strength  of  the  articulations  of  the  pelvis,  dislocation  of  its 
component  bones  is  of  extremely  rare  occurrence ; and,  when  it  does 
happen,  the  amount  of  violence  necessarily  inflicted  will  generally  pro- 
duce fatal  injury  of  the  pelvic  and  abdominal  organs.  The  luxation  is 
always  incomplete. 

Boyer  relates  a case  of  dislocation  of  the  left  ileum  upwards  by  a 
fall  from  a height.  The  anterior  superior  spinous  process  was  above 
the  level  of  the  corresponding  point  upon  the  opposite  side ; the  left 
pubis  was  some  distance  above  the  right ; the  left  leg  was  shorter  than 
the  right,  but  both  of  them  measured  the  same  length  from  the  tro- 
chanter to  the  ankle ; flexion  and  extension  of  the  thigh  gave  rise  to 
pain  in  the  pubic  and  sacro-iliac  symphyses. 

A disturbance  of  the  relation  of  the  two  bones  has  been  observed, 
also,  after  difficult  labor ; the  patient  cannot  walk  without  great  pain, 
from  the  motion  of  the  bones  at  the  symphyses,  and  requires  the 
application  of  a broad  bandage  to  the  pelvis  and  hips  to  hold  the 
bones  in  firm  apposition. 

The  sacrum  may  be  driven  slightly  inwards  by  a violent  blow 
upon  the  back  of  the  pelvis,  and  the  coccyx,  before  ossification, 
may  be  incompletely  dislocated  either  forwards  or  backwards.  In 
the  former  case,  it  results  from  blows  or  falls  upon  the  part;  and  in 
the  latter  case,  from  the  pressure  of  the  head  of  the  child  in  difficult 
labor. 

The  reduction  is  easy.  Introduce  the  point  of  the  index  finger  into 
the  rectum,  and  grasp  the  coccyx  between  the  thumb  and  finger, 
pressing -it  in  a direction  opposite  the  displacement.  There  is  no  dis- 
position to  reluxation. 


548 


PARTICULAR  DISLOCATIONS. 


Dislocation  of  the  Femur. 

The  coxo-femoral  joint  is  one  of  exceeding  strength,  the  large 
globular  head  of  the  femur  being  held  in  a deep  osseous  cavity  by 
strong  ligaments,  and  protected  by  a mass  of  muscles  surrounding  the 
articulation,  presenting  a most  perfect  type  of  the  ball-and-socket 
joint,  which  allows  a wide  range  of  motion. 

The  dislocation  usually  occurs  in  four  principal  directions,  back- 
wards and  upwards  upon  the  dorsum  ilii ; backwards  and  upwards 
into  the  sciatic  notch;  forwards  and  downwards  into  the  thyroid 
foramen;  and  forwards  and  upwards  upon  the  pubic  bone.  From 
some  peculiarity  in  the  application  of  the  force  producing  the  injury, 
or  from  some  other  cause,  it  occasionally  happens  that  the  head  of 
the  femur  passes  in  any  direction  intervening  between  these  four,  so 
that  it  has  been  found  under  the  anterior-superior  spinous  process,  in 
the  lesser  ischiatic  foramen,  upon  the  posterior  part  of  the  body  of  the 
ischium,  below  the  lower  margin  of  the  acetabulum,  and  in  the 
perineum. 

As  to  the  relative  frequency  of  the  four  principal  varieties,  Cooper 
and  Malgaigne  state  it  in  the  order  in  which  they  are  mentioned 
above.  It  is  most  commonly  met  with  in  persons  between  the  ages 
of  twenty  and  forty-five,  being  rare  in  childhood  and  old  age.  Males 
suffer  more  often  than  females  in  the  proportion  of  eight  to  one. 

1.  Iliac  Dislocation. — Iliac  dislocation,  or  that  -where  the  head  of 
the  bone  reposes  upon  the  dorsum  of  the  ilium,  is  caused  by  falls 
upon  the  knee  or  foot  when  the  thigh  is  adducted,  and  somewhat  in 


Fig.  491. 


Iliac  dislocation.  Anatomical  relation. 


Fig.  492. 


advance  of  the  body;  or  by  blows  upon  the  back  of  the  pelvis  when 
a person  is  stooping,  with  the  knees  widely  separated. 


DISLOCATION  OF  THE  FEMUR. 


549 


The  capsular  ligament  is  ruptured,  particularly  at  its  posterior 
part,  and  the  head  of  the  femur  is  thrust  upwards  on  the  dorsum  of 
the  ilium  among  the  fibres  of  the  gluteal  muscles,  which  are  relaxed 
and  folded  upwards,  while  the  adductor  muscles  are  drawn  tense. 
When  the  injury  is  severe,  there  will  be  more  or  less  contusion  and 
effusion  of  blood  into  the  soft  parts  about  the  joint. 

Symptoms. — The  patient  cannot  support  the  weight  of  the  body 
upon  the  injured  limb,  which  will  be  found,  upon  measurement  from 
the  anterior-superior  spinous  process  of  the  ileum  to  the  malleolus, 
from  an  inch  and  a half  to  three  inches  shorter  than  the  other,  the 
average  being  two  inches,  and  cannot  be  drawn  to  its  normal  length 
by  moderate  extension;  the  thigh  is  rotated  inwards,  so  that  the  knee 
touches  the  sound  thigh  just  above  the  patella,  and  the  great  toe  rests 
upon  the  instep  of  the  opposite  foot,  as  seen  in  Fig.  492 ; or  upon  the 
foot  just  below  it.  The  trochanter  is  more  prominent,  and  nearer  the 
spine  of  the  ilium,  and  in  some  persons  the  head  of  the  femur  can 
be  felt  in  its  abnormal  position;  flexion  is  easy,  adduction  less  so, 
and  abduction  is  impossible. 

Diagnosis. — Dislocation  can  be  distinguished  from  fracture  of  the 
upper  extremity  of  the  femur  by  the  following  features : The  short- 
ened limb  cannot  be  restored  to  its  normal  length  by  moderate  exten- 
sion ; the  toes  are  turned  in ; motion  of  the  thigh  at  the  hip  much 
restricted ; and  crepitus  is  absent.  In  fracture,  these  symptoms  are 
exactly  the  reverse. 

Prognosis. — Dislocation  of  the  femur  is  always  a serious  matter, 
though  usually,  in  simple  cases,  where  the  reduction  has  been  accom- 
plished, the  limb,  in  two  or  three  months,  will  become  as  strong  as 
the  sound  one.  Sometimes,  again,  it  remains  stiff  and  weak  for 
months ; and  in  severer  cases,  occasionally  inflammation  of  a chronic 
character  will  arise,  producing  ulceration  of  the  cartilages  and  caries 
of  the  bone ; or  even  acute  inflammation  may  occur,  followed  by 
abscess. 

Treatment. — The  dislocation  may  be  reduced  by  manipulation,  or 
by  extension  and  counter-extension.  In  the  first  instance,  chloroform 
having  been  administered,  if  deemed  necessary,  the  patient  is  placed 
upon  his  back  on  a couch — or,  better  still,  upon  the  floor,  which  will 
enable  the  surgeon  to  have  greater  command  over  the  limb ; he  now 
seizes  the  knee  of  the  injured  limb  in  one  hand,  and  the  ankle  in  the 
other,  and  bends  the  leg  upon  the  thigh ; then  the  knee  is  carried 
across  the  opposite  thigh  upwards  in  the  direction  of  the  correspond- 
ing side  to  the  umbilicus,  when  it  should  be  made  to  sweep  across  the 
abdomen  to  the  injured  side.  From  this  position  the  thigh  is  gra- 
dually brought  down  or  extended,  the  knee  being  pressed  outwards, 
while  the  foot  is  conducted  across  the  sound  limb,  until  the  thighs  are 
side  by  side. 

In  Fig.  493  the  arrows  and  dotted  lines  indicate  directions  pursued 
by  the  knee  and  the  head  of  the  femur. 

It  will  be  found  that  the  reduction  takes  place  when  the  thigh  be- 
gins to  descend  from  a right  angle  with  the  body ; and  should  it  not 
occur  at  this  time  the  movement  may  be  recommenced. 


550 


PARTICULAR  DISLOCATIONS. 


Should  a resort  to  the  pulleys  be  determined  on,  the  patient  should 
be  placed  on  his  back  upon  a narrow  table,  and  thoroughly  chloro - 

Fig,  493. 


Diagram  showing  the  mechanism  of  reduction  of  the  hip  by  the  flexion  method. 


formed.  An  extending  band  is  fixed  upon  the  lower  part  of  the 
thigh,  which  may  be  the  ordinary  leather  strap  with  buckles,  applied 
over  a wetted  roller,  or  two  pieces  of  some  strong  cloth,  two  feet  long 
and  about  four  inches  wide,  laid  upon  the  sides  of  the  limb,  and 
secured  above  the  knee  by  a wetted  roller.  The  ends  of  the  strips  are 
then  knotted  together  to  form  a loop  upon  each  side  of  the  thigh. 
The  counter-extending  band  is  prepared  by  rolling  up  a sheet  into  a 
cord,  the  centre  of  which  is  placed  in  the  perineum,  and  its  extremi- 
ties brought  upwards  over  the  hip  of  the  injured  side,  to  be  fastened 
to  a staple  fixed  in  the  wall.  The  pulleys  are  to  be  hooked  at  one 
end  to  a staple  driven  into  the  wall  at  an  opposite  point,  and  at  the 
other  to  the  extending  band  in  such  a manner  that  the  extending  and 
counter-extending  forces  shall  act  in  opposite  directions  in  the  axis 
of  the  femur.  The  thigh  of  the  injured  limb  should  be  bent  some- 


Fig.  494. 


Method  of  reducing  dislocated  liip  with  pulleys. 


what  upon  the  abdomen,  so  as  to  point  across  the  opposite  leg  just 
above  the  knee,  as  seen  in  Fig.  494. 


DISLOCATION  OP  THE  FEMUR. 


551 


An  assistant  should  stand  by  the  table,  and  with  his  hands  steady 
the  patient’s  hips;  a second  assistant  takes  hold  of  the  leg  to  rotate 
the  thigh  gently,  when  so  directed  by  the  surgeon,  who  takes  his 
position  at  the  hip  of  the  injured  side,  with  a strip  of  muslin  passing 
around  his  neck  and  the  upper  part  of  the  thigh,  by  means  of  which 
he  raises  the  head  of  the  bone,  when  it  is  brought  down  to  the  aceta- 
bulum. The  force  applied  to  the  pulleys  should  be  gentle  and  con- 
tinuous, in  order  to  gradually  fatigue  and  extend  the  muscles;  quick 
pulling  or  jerking  upon  the  cord  will  add  to  the  difficulties  of  the 
reduction  by  stimulating  them  to  stronger  contraction. 

The  after-treatment  consists  in  keeping  the  patient  in  bed  with  his 
thighs  tied  together,  the  injured  one  being  rotated  a little  outwards, 
for  fifteen  or  twenty  days. 


Fig.  495.  Fig.  496. 


External  appearance  of  sciatic  dislocation. 


2.  Sdatic  Dislocation. — Sciatic  dislocation,  or  that  in  which  the  head 
of  the  femur  rests  in  the  sciatic  notch  (Fig.  495),  is  caused  by  falls  or 


552 


PABTICULAR  DISLOCATIONS. 


blows  upon  the  knees  or  feet  when  the  thighs  are  strongly  flexed  upon 
the  abdomen,  or  the  body  upon  the  thighs. 

The  capsular  ligament  is  ruptured  at  its  posterior  part,  the  teres 
ligament  torn  through,  and  the  psoas-magnus,  iliacus  internus,  and 
obturator  muscles  tensely  stretched. 

Symptoms. — The  symptoms  of  this  dislocation  are  similar  to  those 
of  the  iliac  variety ; the  limb  will  be  shortened  from  half  an  inch  to 
an  inch ; the  thigh  flexed,  and  the  knee  projecting  in  front  of  the 
opposite  one,  but  not  so  much  as  in  iliac  luxation;  the  toes  rest  upon 
the  ball  of  the  toe  of  the  other  foot  (Fig.  496) ; the  trochanter  is  farther 
off  from  the  crest  of  the  ilium,  and  the  head  of  the  bone  can  be  rarely 
felt  in  its  new  position ; the  thigh  is  immovable ; and,  according  to  Mr. 
Syme,  there  is  “ an  arched  form  of  the  lumbar  part  of  the  spine, 
which  cannot  be  straightened  so  long  as  the  thigh  is  straight,  or  on  a 
line  with  the  patient’s  trunk.  When  the  limb  is  raised  or  bent  up- 
wards upon  the  pelvis,  the  back  rests  flat  upon  the  bed ; but  as  soon 
as  the  limb  is  allowed  to  descend,  the  back  becomes  arched  as  before.” 

Treatment. — The  method  of  reduction  by  flexion  is  the  same  as  in 
the  previous  case.  In  the  application  of  the  pulleys  the  patient 
should  be  placed  upon  the  sound  side,  and  after  having  arranged  the 
extending  and  counter-extending  bands  in  the  manner  already  pointed 
out,  the  line  of  traction  should  be  made  across  the  middle  of  the  oppo- 
site thigh,  as  seen  in  Fig.  497,  until  the  muscles  are  sufficiently 
fatigued  to  permit  the  head  of  the  bone  to  be  dislodged  from  the 


Fig.  497. 


sciatic  notch,  when  it  must  be  pulled  forward  to  the  acetabulum  by 
the  lac  placed  around  the  upper  part  of  the  thigh  and  over  the  sur- 
geon’s neck. 

The  after-treatment  is  the  same  as  in  the  former  case. 

3.  Thyroid  Dislocation. — This  is  caused  by  force  applied  to  the  knee 
or  foot  while  the  limb  is  abducted  and  posterior  to  the  plane  of  the 
body ; or  by  heavy  weights  falling  upon  the  loins  or  hips  while  the 
body  is  bent  forwards  and  the  legs  widely  separated. 

The  teres  and  capsular  ligaments  (the  latter  notably  upon  its  inner 
side)  are  ruptured,  and  the  head  of  the  femur  escapes  from  the  cotv- 


DISLOCATION  OF  THE  FEMUR. 


553 


bid  cavity,  and  assumes  a position  upon  the  external  obturator 
muscle  over  the  thyroid  foramen,  the  trochanter  looking  towards  the 
acetabulum  (Fig.  498). 

Symptoms. — The  thigh  is  slightly  flexed  and  the  body  bent  forwards 
in  consequence  of  the  psoas  muscle  being  put  upon  the  stretch ; the 
: limb  is  lengthened  one  or  two  inches,  and  abducted ; efforts  to  abduct, 


extend,  and  rotate  it,  are  extremely  painful ; while  the  former  move- 
ment is  impossible ; the  foot  is  generally  turned  forwards ; the  hip  is 
flattened,  and  the  head  of  the  femur  can  be  felt  at  the  upper  and  inner 
surface  of  the  thigh  (Fig.  499). 

Diagnosis. — The  immobility  of  the  thigh,  abduction  and  lengthening 
of  the  limb,  the  turning  forwards  of  the  toes,  and  flattening  of  the  nates 
will  so  characterize  this  dislocation  as  to  prevent  its  being  mistaken 
for  fracture  of  the  neck  of  the  femur. 

Treatment. — The  flexion  method  may  also  be  applied  in  this  case. 
The  thigh  is  flexed,  and,  in  bringing  it  down  again,  instead  of  rotating 
it  outwards  as  in  the  former  cases,  it  must  be  rotated  inwards,  so  as 
to  throw  the  head  of  the  bone  towards  the  acetabulum.  It  should  be 
remarked,  however,  that,  in  certain  cases  recorded,  the  reduction  was 
accomplished  by  outward  rotation. 

Sir  A.  Cooper’s  plan  with  the  pulleys  is  to  be  conducted  in  this 
manner : Place  the  patient  on  his  back  ; around  the  upper  part  of  the 
, thigh  put  an  extending  band,  to  which  the  pulleys  are  hooked  by 


Fig.  498. 


Fig.  499. 


Thyroid  dislocation. 


External  appearances  of  thyroid  dislocation. 


554 


PARTICULAR  DISLOCATIONS. 


one  of  its  extremities,  the  other  being  attached  to  a point  in  the  wall 
opposite  the  injured  hip  ; the  counter-extending  band  is  passed  around 

the  hips,  and  through  the  noose  of 
the  extending  lac,  and  drawn  over 
to  the  sound  side  to  be  fixed  to  a 
corresponding  point  in  the  opposite 
wall  (Fig.  500). 

Force  is  now  applied  to  the  pul- 
leys to  extricate  the  head  of  the 
femur  from  the  thyroid  foramen, 
when  the  surgeon,  passing  his  hand 
behind  the  sound  limb,  seizes  the 
ankle  of  the  opposite  one  and 
draws  it  towards  him,  making  a 
lever  of  the  first  order  of  the 
injured  limb  to  throw  the  head  of 
the  bone  towards  the  acetabulum, 
when  the  extending. pulleys  should 
be  loosened,  and  the  reduction 
will  be  effected. 

4.  Pubic  Dislocation  (Fig.  501). 
—This  is  the  rarest  of  the  four 
varieties.  It  is  caused  by  forces 
acting  in  the  same  manner  as  in 
thyroid  luxation;  and  particularly 
when  the  limb  is  thrown  very 
much  in  the  rear  of  the  body  at  the 
time  of  the  injury. 

The  capsular  ligament  is  rup- 
tured at  its  inner  and  upper  por- 
tion, the  head  of  the  femur  escapes 
and  slips  upwards  upon  the  pubis  outside  of  the  pectineal  eminence 
under  cover  of  the  psoas  magnus  and  iliacus  internus. 

Symptoms. — The  limb  is  shortened  about  an  inch  and  abducted; 
the  movements  of  adduction  and  rotation  cannot  be  executed;  the 
toes  turn  out  (Fig.  502) ; the  head  of  the  bone  can  be  felt  in  the  groin 
below  Poupart’s  ligament ; the  hip  is  flattened ; and  the  fold  separating 
the  femoral  and  gluteal  regions  higher  up  than  it  is  upon  the  sound  side. 

Treatment. — The  reduction  was  effected  in  a case  by  Malgaigne  in 
the  following  manner : The  thigh  was  flexed  upon  the  abdomen, 
abducted  a little,  then  rotated  inwards,  and  finally  brought  down 
adducted. 

In  using  the  pulleys  the  patient  is  placed  upon  his  back,  the  counter- 
extending band  is  fixed  in  the  wall  above  the  table,  and  the  pulleys  to 
an  opposite  point  below  it ; then  with  the  thighs  widely  separated, 
the  forces  are  made  to  act  in  opposite  directions  in  the  line  of  the 
axis  of  the  thigh,  as  seen  in  Fig.  508.  When  the  head  of  the  bone 
is  moved  from  its  position,  it  may  be  lifted  into  its  socket  by  a towel 
passing  around  the  upper  part  of  the  thigh  and  around  the  neck  of 
the  surgeon. 


Fig.  500. 


DISLOCATION  OF  THE  FEMUR. 


555 


Fig.  501. 


Pubic  dislocation. 


Fig.  502. 


5.  Unusual  Dislocations. — The  head  of  the  femur  has  Teen  observed 
to  occupy  a position  between  the  anterior  superior  and  the  anterior 

Fig.  503. 


inferior  spinous  processes,  or  in  front  or  somewhat  behind  the  latter. 
The  symptoms  are,  shortening  of  the  limb,  the  toes  excessively  everted, 
And  the  head  of  the  bone  can  be  felt  in  its  abnormal  position.  The 
dislocation  may  be  reduced  by  flexing  the  thigh,  abducting  and  rotat- 
ing it  inwards,  and  finally  bringing  it  down  adducted ; pressure  upon 
the  head  of  the  bone  with  the  fingers  will  contribute  to  a successful 
result. 

It  has  also  been  seen  displaced  directly  downwards ; “ the  limb  was 
lengthened  three  inches  and  a half,  and  was  fixed  and  everted ; the 


556 


PARTICULAR  DISLOCATIONS. 


trochanter  was  sunk ; and  the  head  of  the  bone  close  to  and  on  a 
level  with  the  tuberosity  of  the  ischium,  where  it  was  capable  of 
being  moved  under  the  fingers. 

Three  other  anomalous  forms  of  the  dislocation  have  been  recorded, 
viz.,  upon  the  body  of  the  ischium  between  its  tuberosity  and  spine, 
into  the  lesser  sciatic  notch,  and  forwards  into  the  perineum. 

In  such  cases  the  reduction  may  be  effected  by  the  flexion  method, 
upon  the  principle  already  laid  down  for  the  other  forms  of  luxations, 
due  allowance  being  made  for  the  differences  in  anatomical  relations 
of  the  head  of  the  femur. 

Dislocation  of  the  Patella. 

The  patella  may  be  dislocated  in  four  directions:  outwards,  inwards, 
upwards,  and  upon  its  own  axis. 

Dislocation — 

1.  Outwards. 

2.  Inwards. 

3.  Upwards. 

4.  Upon  its  own  axis. 

1.  Dislocation  outwards. — This  is  the  most  frequent  variety,  and  may 
be  incomplete  or  complete,  the  former  being  the  most  common. 

In  incomplete  luxation  the  tissues  about  the  joint  are  not  damaged 
to  any  great  extent ; while  in  the  complete  variety  the  capsular  liga- 
ment is  torn  through,  and  the  ligamentum  patellae 
more  or  less  lacerated  ; sometimes  the  other  ligaments 
about  the  joint  are  also  concerned  in  the  injury. 

Causes. — The  causes  are  external  violence  applied 
to  the  inner  edge  of  the  patella,  and  muscular  action. 
It  should  be  noticed  that  the  inner  margin  of  the 
patella  is  thicker  than  the  outer,  and  much  less  pro- 
tected by  its  corresponding  condyle. 

Symptoms. — The  knee  is  more  or  less  flexed  and 
immovable;  the  inner  margin  of  the  patella  can  be 
felt  inclining  forwards  and  outwards  when  the  dislo- 
cation is  incomplete,  or  looking  directly  forwards 
when  complete.  In  the  latter  position  the  vastus 
internus  is  put  upon  the  stretch,  which  can  be  easily 
felt  along  the  inner  side  of  the  thigh,  while  the  liga- 
ment of  the  patella  is  drawn  tense  from  below  out- 
wards, and  forms  a prominent  ridge ; a depression 
will  be  formed  over  the  condyles  from  the  absence 
of  the  patella  ; and  the  inner  condyle  is  observed  to 
project  unnaturally. 

Prognosis. — Usually  the  luxated  bone  can  be  replaced  with  ease 
and  no  unfavorable  results  follow;  there  are  cases,  however,  where 
the  parts  never  regain  their  wonted  vigor ; so  that  the  patella  is 
readily  luxated  again  upon  the  application  of  slight  force. 


Fig.  504. 


Dislocation  of  the  pa- 
tella outwards. 


DISLOCATION  OF  THE  TIBIA. 


557 


Fis;.  505. 


Treatment. — Place  the  patient  upon  his  back,  or,  better  still,  let  him 
sit  in  a chair ; then  extend  the  leg  upon  the  thigh,  and  flex  the  thigh 
strongly  upon  the  abdomen,  so  as  to  thoroughly  relax 
he  extensor  quadriceps ; then  make  pressure  upon 
he  outer  border  of  the  patella  with  the  two  thumbs, 

,vhen  it  will  resume  its  natural  position. 

When  the  reduction  is  effected  keep  the  limb  at 
[rest  for  four  or  five  weeks  by  means  of  a posterior 
;plint  bound  to  it  with  a roller  bandage. 

2.  Dislocation  inwards. — This  injury  is  caused  by 
flows  upon  the  outer  margin  of  the  patella.  Its 
lymptoms  will  differ  from  those  already  noted  in 
Connection  with  outward  dislocation  only  so  far  as 
hey  must  necessarily  be  modified  from  the  position 
>f  the  patella  upon  the  inner  condyle.  The  treatment 
Ijs  the  same. 

8.  Dislocation  upwards. — It  results  from  the  ex- 
cessive relaxation  of  the  ligamentum  patellae ; it  has 
been  seen  to  ascend  the  thigh  as  much  as  three  inches. 

The  treatment  in  such  a case  would  be  the  appli- 
cation of  one  of  the  apparatus  described  in  the 
rticle  on  fractured  patella. 

4.  Dislocation  of  the  Patella  upon  its  Axis. — This  is  a very  rare  form 
>f  injury,  and  results  from  the  same  causes  as  the  other  varieties.  The 
latella  may  occupy  three  distinct  positions,  according  to  the  nature 
nd  direction  of  the  force  causing  the  dislocation : its  inner  border 


Dislocation  of  the  pa- 
tella inwards. 


nay  repose  upon  the  inter-condyloid  space,  with  the  outer  border 
irojecting  forwards ; or  the  reverse  may  occur,  which  is  much  more 
ommon ; or  the  patella  may  be  twisted  completely  around,  so  that  its 
,'osterior  face  shall  present  anteriorly. 

Symptoms. — The  sharp  margins  of  the  patella  can  be  felt  in  the 
aedian  line  of  the  joint,  forming  a ridge  from  which  two  planes  slope 
jutwards  to  the  borders  of  the  articulation,  instead  of  the  naturally 
bunded  outline  of  this  part ; the  limb  is  extended  and  immovable ; 
nd  the  patient  suffers  severe  pain. 

Treatment. — The  same  method  of  reduction  may  be  tried  in  this 
ase  as  in  the  first;  if  this  should  not  succeed,  as  it  will  not  sometimes, 
ie  leg  should  be  forcibly  flexed  upon  the  thigh,  and  then  extended, 
ressure  being  made  at  the  same  time  upon  the  upper  and  lower  mar- 
ks of  the  patella  in  opposite  directions. 


Dislocation  of  the  Tibia. 

From  the  great  size  and  strength  of  the  knee-joint,  dislocations  of 
le  tibia  are  uncommon,  and,  when  they  do  occur,  are  generally  in- 
bmplete.  They  are  caused  by  violent  blows  upon  the  lower  part  of 
■ie  thigh  while  the  leg  is  firmly  fixed  ; or  by  violence  applied  to  the 
g while  the  thigh  is  fixed ; or,  lastly,  by  violent  rotation  of  the  leg 
pon  the  thigh  as  an  immovable  centre,  or  the  reverse. 


558 


PARTICULAR  DISLOCATIONS. 


Dislocation — 

1.  Backwards. 

2.  Forwards. 

3.  Inwards. 

4.  Outwards. 

5.  By  Rotation. 


Fig.  506. 


1.  Dislocation  backwards. — This  is  the  most  common  of  these  five 
varieties.  If  the  luxation  is  complete,  the  posterior  and  crucial  liga- 
ments are  lacerated,  and  the  ligamentum  patellae 
and  gastrocnemius  muscle  put  upon  the  stretch, 
as  well  as  the  nerves  and  bloodvessels  in  the 
popliteal  space ; the  head  of  the  tibia  is  thrown 
back  of  the  femoral  condyles. 

Symptoms. — If  the  dislocation  is  complete,  the 
limb  may  be  shortened  a half  or  three-quarters 
of  an  inch,  and  it  is  usually  in  a position  of 
extreme  extension,  though  it  may  be  straight  or 
flexed;  the  head  of  the  tibia  projects  strongly 
in  the  rear,  while  the  condyles  hang  over  the 
patella  in  front,  causing  a marked  depression 
below  them,  across  which  the  tendon  of  the  ex- 
tensor quadriceps  is  tensely  stretched. 

Prognosis. — When  the  injury  to  the  joint  is 
inconsiderable,  and  the  dislocation  has  been 
promptly  reduced,  the  patient  usually  makes  a 
speedy  recovery ; on  the  other  hand,  there  are 
cases  in  which  months  elapse  before  the  func- 
tions of  the  limb  are  restored.  In  very  severe 
injury  to  the  articulation,  excessive  inflammation,  with  suppuration, 
sometimes  follows,  often  requiring  amputation  or  resection.  A dis- 
position to  reluxation,  and  an  inability  to  keep  the  leg  straight  in  the 
erect  posture,  have  also  been  noted  as  an  occasional  result  of  this 
dislocation. 

Treatment. — The  dislocation  may  be  reduced  by  making  extension 
and  counter-extension  from  the  ankle  and  thigh,  or,  better  still,  from 
the  perineum,  while  the  surgeon  presses  the  bones  in  opposite  direc- 
tions to  the  displacement.  Sometimes  alternate  flexion  and  extension, 
with  slight  rotation  of  the  leg,  will  accomplish  the  object  at  once. 

After-treatment.— The  patient  should  be  kept  in  his  bed  five  or  six 
weeks,  with  the  limb  in  a straight  position,  and  inflammatory  action 
controlled  by  antiphlogistics;  afterwards,  gentle  movements  should  he 
impressed  upon  the  joint,  to  prevent  anchylosis. 

2.  Dislocation  forwards. — This  differs  from  the  preceding  variety 
in  the  head  of  the  tibia  being  thrown  in  front  of  the  condyles,  instead 
of  behind,  forming  a prominence  anteriorly,  upon  the  top  of  which 
the  patella  reposes.  The  limb  is  shortened  from  one  to  four  inches 
if  the  luxation  is  complete,  and,  viewed  from  behind,  the  leg  appears 
unnaturally  short,  while  a front  view  convej’s  the  impression  that  the 


Dislocation  of  the  head  of 
the  tibia  backwards. 


DISLOCATION  OF  THE  TIBIA. 


559 


thigh  is  lengthened.  The  movements  are  not  so  difficult  as  in  the 
previous  case. 

The  treatment  is  the  same  as  in  dislocation  backwards. 


Fig.  507. 


Dislocation  forwards. 


Fig.  508. 


Incomplete  dislocation  outwards. 


3.  Dislocation  outwards. — This  is  almost  always  partial.  Malgaigne 
has  reported  one  case  where  the  head  of  the  tibia  passed  to  the  outside 
of  the  external  condyle,  and  rose  above  the  level  of 
its  articular  surface. 

Symptoms .- — The  limb  presents  a twisted  appear- 
ance, and  the  leg  is  slightly  flexed  and  rotated  on 
its  axis;  the  joint  is  increased  in  breadth,  the  tibia 
projecting  externally,  forming  a tumor  upon  the 
outside  of  the  articulation  ; the  inner  femoral  con- 
dyle is  equally  prominent  upon  the  inner  aspect  of 
the  limb;  and  the  patella  is  pushed  outwards. 

The  treatment  does  not  differ  from  that  of  pos- 
terior luxation. 

4.  Dislocation  inwards. — This  variety  of  disloca- 
tion is  the  reverse  of  the  preceding ; the  head  of 
the  tibia  is  displaced  inwards,  so  that  the  inner 
condyle  of  the  femur,  rests  upon  the  centre  of  its 
articulating  surface.  The  symptoms  and  treatment 
will  be  the  same  as  in  luxation  outwards,  except 
so  far  as  these  must  necessarily  vary  from  the  op- 
posite position  of  the  head  of  the  tibia. 

5.  Dislocation  by  Rotation. — This  injury  occurs 
when  the  leg  is  twisted  inwards  or  outwards  so  as  to  throw  one  of  the 
femoral  condyles  from  its  articulating  facet,  while  the  other  remains 
jin  its  natural  position. 

Symptoms. — Rotation  of  the  leg  inwards  or  outwards,  according  as 
ts  inner  or  outer  articular  facet  is  displaced;  it  is  slightly  flexed;  and 
;he  joint  is  altered  in  shape. 


Fig.  509. 


Incomplete  dislocation 
inwards. 


560 


PARTICULAR  DISLOCATION'S. 


Treatment. — Extension  and  pressure  upon  the  head  of  the  tibia,  with 
rotation  of  the  leg  in  a direction  opposite  that  of  the  displacement. 

Dislocation  of  the  Semilunar  Cartilages. 

Dislocation  of  the  semilunar  cartilages  results  from  a sudden  twist- 
ing of  the  knee-joint  by  striking  the  toes  against  an  obstacle,  or 
making  a false  step.  One  of  the  cartilages  is  thereby  displaced,  and, 
in  some  cases,  may  be  almost  entirely  separated  from  its  connection 
with  the  articular  surface  of  the  tibia,  and  become  wedged  between 
the  joint-surfaces. 

Symptoms. — The  patient  is  aware  that  something  has  given  way  in 
the  knee-joint,  and  he  finds  that  he  can  neither  support  the  weight  of 
the  body  upon  the  limb  nor  fully  extend  the  leg ; he  suffers  severe 
pain  in  the  knee,  and  feels  sick  and  faint ; and  after  the  lapse  of  a 
few  hours  the  articulation  becomes  swollen  and  tender. 

Treatment. — The  cartilage  may  be  restored  to  its  natural  position 
by  placing  the  patient  upon  his  back,  then  raising  the  limb  from  the 
bed,  let  the  surgeon  support  the  ham  upon  his  left  arm,  while  he 
grasps  the  ankle  in  his  left  hand,  and  flexes  the  leg,  rotating  it  at  the 
same  time  outwards ; then  let  him  suddenly  extend  it. 

Mr.  Fergusson  relates  the  case  of  a patient  who  could  effect  a re- 
placement of  the  cartilage  by  pointing  the  toes  outwards  as  much  as 
possible,  and  then  lifting  the  foot  forward,  with  the  opposite  foot 
behind  the  tendo-  Achillis ; and  Sir  A.  Cooper  tells  of  a person  who 
accomplished  the  same  object  by  bending  the  thigh  inwards,  and  draw- 
ing the  foot  outwards,  while  he  sat  upon  the  floor. 

In  order  to  support  the  joint,  and  thus  prevent  a renewal  of  the 
luxation,  the  patient  should  wear  an  elastic  knee-cap. 

Dislocation  of  the  Fibula. 

I.  Dislocation  of  the  Upper  Extremity — 

1.  Forwards. 

2.  Backwards. 

II.  Lower  Extremity — 

Backwards. 

1.  Dislocation  of  the  Upper  Extremity  of  the  Fibula.  1.  Dislocation 
forwards. — There  are  but  three  recorded  examples  of  this  dislocation, 
which  results  from  muscular  action,  or  direct  force  applied  to  the 
upper  extremity  of  the  fibula.  It  is  recognized  by  the  tumor  caused 
by  the  displaced  head  of  the  bone,  near  the  tubercle  of  the  tibia ; the 
tendon  of  the  biceps  flexor  will  be  drawn  forwards  out  of  its  normal 
situation;  and  marked  depression  will  be  observed  below  and  upon 
the  outer  side  of  the  knee. 

In  the  treatment  of  this  luxation  pressure  must  be  made  upon  the 
head  of  the  fibula  backwards  to  force  it  into  its  natural  position. 

2.  Dislocation  backwards. — This  is  caused  in  the  same  manner  as 
forward  luxation.  In  a case  reported  by  Dubreuil  the  head  of  the 
fibula  formed  a tumor  posteriorly ; the  foot  was  drawn  outwards,  and 
the  whole  outside  of  the  limb  was  cold  and  numb. 


DISLOCATION  OF  THE  FOOT. 


561 


The  reduction  was  effected  by  flexing  the  leg  moderately,  and  press- 
ing upon  the  head  of  the  fibula  from  behind  forward. 

II.  Dislocation  of  the  Lower  Extremity  of  the  Fibula.  Dis- 
location backwards.- — -The  only  case  of  this  variety  of  luxation  is 
recorded  by  Nelaton.  It  was  caused  by  the  passage  of  a wheel  over 
the  upper  part  of  the  leg.  The  lower  end  of  the  fibula  was  forced 
backwards  so  as  to  be  almost  in  contact  with  the  tendo-Achillis ; the 
, outer  face  of  the  astragalus,  uncovered  by  the  external  malleolus, 
|:  could  be  distinctly  felt;  the  foot  was  in  a natural  position.  The 
patient  presented  himself  at  the  hospital  thirty  days  after  the  accident, 
and  it  was  not  deemed  advisable  to  make  any  efforts  at  reduction. 

| 

Dislocation  of  the  Foot  (Astragalus  upon  the  Tibia  and 

Fibula). 

The  astragalus  may  be  dislocated  upon  the  bones  of  the  leg  in  the 
direction  indicated  in  the  following  table  : — 

Dislocation — 

1.  Forwards. 

2.  Backwards. 

3.  Inwards. 

4.  Outwards. 

5.  Upwards. 

6.  By  Rotation. 

1.  Dislocation  forwards  (Fig.  510). — This  is  the  most  uncommon  of 
the  five  varieties  of  luxation  affecting  the  ankle-joint.  It  is  caused  by 
falls  upon  the  heel  while  the  foot  is  strongly  flexed. 

The  ligaments  about  the  articulation  are  ruptured,  and  the  astra- 
galus is  forced  forwards  in  front  of  the  lower  end  of  the  tibia. 


Fig.  510.  Fig.  511. 


Symptoms. — The  symptoms  are : Lengthening  of  the  foot  in  front 
of  the  malleoli,  and  a corresponding  shortening  of  the  heel,  which 
forms,  with  the  posterior  surface  of  the  leg,  a straight  line;  the  leg  is 
36 


562 


PARTICULAR  DISLOCATIONS. 


somewhat  shorter  than  the  other,  and  the  malleoli  approach  nearer 
the  sole  of  the  foot  and  heel  (Fig.  511). 

Treatment. — For  accomplishing  the  reduction,  the  patient  should  he 
placed  upon  the  injured  side,  with  the  thigh  raised  perpendicular  to 
the  trunk,  and  the  leg  flexed  at  a right  angle  with  the  thigh,  so  that 
the  muscles  of  the  calf  of  the  leg  shall  be  relaxed.  An  assistant  sup- 
ports the  thigh,  and  makes  counter-extension,  while  the  surgeon 
grasps  the  foot  in  his  hands  and  draws  it  downwards;  at  the  same  time 
he  endeavors  to  carry  it  backwards,  in  order  to  place  the  astragalus 
beneath  the  tibia. 

The  limb  may  be  subsequently  semiflexed,  and  placed  upon  a 
double-inclined  plane,  with  a compress  just  above  the  heel. 

2.  Dislocation  backwards  (Fig.  512). — This  dislocation  is  exactly  the 
reverse  of  the  preceding.  It  is  caused  by  violent  extension  of  the 
foot,  as  when  its  anterior  part  is  firmly  held  while  the  body  is  thrown 
backwards.  'The  lower  extremity  of  the  fibula  is  commonly  broken, 
and  the  ligaments  considerably  lacerated.  It  may  be  complete  or  in- 
complete. 


Symptoms. — The  anterior  part  of  the  foot  will  be  shortened,  while 
the  heel  is  elongated,  and  the  tendo-Achillis  prominent.  The  astra- 
galus can  be  distinctly  felt  behind  the  ankle,  and  the  end  of  the  tibia 
in  front  of  it ; and  the  toes  are  depressed  with  a corresponding  eleva- 
tion of  the  heel  (Fig.  513). 

Treatment. — The  reduction  can  be  easily  accomplished  by  extension 
in  the  manner  directed  for  dislocation  forwards ; there  is,  however, 
greater  difficulty  encountered  in  maintaining  it,  as  the  bones  have  a 
constant  disposition  to  slip  from  contact  with  each  other. 

Dupuytren  recommends  that  his  splint  for  fractured  fibula  should 
be  applied  after  the  reduction,  and  the  limb  laid  upon  its  side  in  a 
semiflexed  position ; and  Malgaigne  employed  in  one  case  success- 
fully a boot-shaped  splint  of  plaster  of  Paris. 

Should  there  not  be  any  contra-indication  present,  the  starch 


Fig.  512, 


Fig.  513, 


Dislocation  of  the  foot  backwards. 


DISLOCATION  OF  THE  FOOT. 


563 


bandage  applied  to  the  foot  and  leg,  would  be  serviceable;  while  in 
those  cases  where  there  is  much  swelling  and  inflammation,  the  leg 
may  be  placed  in  an  ordinary  fracture-box,  with  the  foot  secured  to 
the  footboard,  the  forward  tendency  of  the  tibia  being  overcome  by 
compresses  placed  in  front  of,  and  above  the  ankle. 

3.  Dislocation  inwards  (Fig.  514). — In  this  luxation,  the  astragalus  is 
either  completely  displaced  inwards  by  slipping  horizontally  inwards 
from  the  articular  surface  of  the 

tibia,  or  it  rotates  upon  its  axis  FiS-  514- 

so  as  to  place  its  inner  and 
upper  margin  against  the  mid- 
dle portion  of  that  surface  in 
such  a manner  that  its  superior 
surface  looks  outwards. 

The  tibio-tarsal  ligaments  are 
usually  ruptured,  and  the  inner 
malleolus  fractured;  sometimes 
they  are  entire,  and  in  that  case 
the  fibula  will  give  way  above 
the  malleolus,  the  lower  frag- 
ment remaining  in  connection 
with  the  tarsus ; in  other  in- 
stances the  tibio-tarsal  ligaments 
will  remain  untorn,  and  both 
malleoli  are  fractured. 

Causes. — Falls  upon  the  foot, 
forcing  it  into  an  extreme  de- 
gree of  abduction ; it  is  some- 
times the  result  of  direct  vio- 
lence, as  the  passage  of  a vehi- 
cle over  the  ankle. 

Symptoms. — The  foot 'is  turned 
inwards,  and  the  external  mal- 
leolus forms  a remarkable  pro- 
minence upon  the  outer  ankle ; 
and  the  astragalus  can  be  easily 
felt  beneath  the  inner  malleo- 
| lus. 

Prognosis. — This  injury  can  only  be  produced  by  great  force,  which 
renders  the  prognosis  always  serious.  It  is  often  followed  by  severe 
inflammation  and  profuse  suppuration,  resulting  in  anchylosis. 

Treatment.— The  reduction  is  accomplished  in  the  same  general 
manner  as  previously  described  for  luxation  forward.  The  extension 
should  first  be  made  in  the  direction  of  the  displacement,  and  when 
the  astragalus  begins  to  move  in  the  axis  of  the  leg,  the  surgeon  at 
the  same  time  abducts  the  foot,  to  throw  the  astragalus  beneath  the 
articulating  surface  of  the  tibia. 

In  both  of  the  lateral  dislocations  it  may  be  necessary  to  apply 
more  force  than  can  be  effected  with  the  hands,  when  recourse  should 
be  had  to  the  pulleys  in  the  manner  shown  in  Fig.  515. 


Dislocation  of  the  foot  inwards. 


564 


PARTICULAR  DISLOCATIONS. 


The  after-treatment  consists  in  applying  two  side-splints  of  gutta- 
percha, neatly  moulded  to  the  foot  and  ankle,  so  that  these  parts  may 

Fig.  515. 


be  thoroughly  supported ; the  inflammatory  action  is  to  be  combated 
by  appropriate  remedies. 

If  fracture  of  the  fibula  complicates  the  dislocation,  the  splint  of 
Dupuytren  should  be  employed. 

Fig.  516. 


4.  Dislocation  outwards  (Fig.  516). — It  is  the  most  common  luxation  of 
the  ankle ; the  astragalus  rotates  inwards,  so  that  its  outer  and  upper 


DISLOCATION  OF  THE  TARSUS. 


565 


border  is  in  contact  with  the  articular  surface  of  the  tibia,  and  its 
superior  plane  looks  inwards.  This  peculiar  position  of  the  astragalus 
cannot  be  assumed  without  a rupture  of  the  tibio-tarsal  ligaments  and 
a fracture  of  the  fibula  above  the  joint.  There  is  also  often  found  an 
oblique  fracture  upwards  and  outwards  through  the  outer  margin  of 
the  articular  surface  of  the  tibia. 

Causes. — The  causes  of  this  luxation  are  falls  upon  the  sole  of  the 
foot  when  it  is  somewhat  abducted ; and  direct  violence. 

Symptoms. — The  foot  is  abducted  and  the  inner  malleolus  produces 

I a protuberance  beneath  the  skin  upon  the  inner  side  of  the  foot ; the 
inner  margin  of  the  foot  rests  upon  the  ground  while  its  outer  border 
is  turned  upwards ; there  is  a depression  above  the  outer  malleolus 
over  the  seat  of  fracture  where  crepitus  may  be  elicited ; and  the 
astragalus  can  be  easily  perceived  beneath  the  external  malleolus. 

Treatment. — Extension  should  be  made  from  the  foot  in  the  manner 
we  have  already  pointed  out ; and  when  the  reduction  is  effected 
Dupuytren’s  splint  must  be  applied ; or  a gutta-percha  splint,  or  a tin 
I case,  may  be  employed  which  shall  perfectly  sustain  the  foot  and 
! ankle.  An  important  point  in  applying  dressings  in  these  dislocations 
is  that  in  order  that  there  may  be  no  constriction  of  the  parts  by  inflam- 
matory swelling,  the  splints  and  bandages  should,  at  first,  be  put  on 
i loosely. 

5.  Dislocation  upwards. — The  astragalus  may  be  forced  upwards 
between  the  tibia  and  fibula,  the  latter  bone  being  in  such  a case 
always  broken  at  its  lower  extremity. 

Symptoms.- — The  symptoms  are  the  following : The  distance  between 
the  malleoli  is  increased,  which  gives  the  appearance  of  great  breadth 
to  the  ankle;  the  inner  malleolus  projects  nearly  to  a level  with  the 
sole  of  the  foot,  the  opposite  one  being  raised,  sometimes  as  much  as 
two  or  three  inches ; and  the  leg  is  shortened. 

Causes. — A fall  upon  the  sole  of  the  foot  in  such  a manner  that  the 
weight  of  the  body  is  transmitted  to  the  instep  vertically. 

Treatment. — The  reduction  is  often  difficult ; it  is  effected  by  ex- 
tension and  counter-extension ; the  leg  should  then  be  placed  in  a 
fracture-box,  and  antiphlogistic  remedies  employed  until  the  inflam- 
mation has  subsided,  when  a pasteboard  splint  may  be  substituted 
for  it. 

6.  Dislocation  by  rotation. — Huguier  records  a case  where  the  foot 
was  violently  twisted  outwards,  while  the  leg  was  held  firmly,  so  that 
the  heel  was  nearly  brought  under  the  inner  malleolus,  and  the  toes 
rotated  outwards  through  a half  of  a circle. 

Treatment. — Extension  and  rotation  of  the  foot  inwards. 

Dislocation  of  the  Tarsus. 

I.  Astragalus. 

1.  Forwards. 

2.  Backwards. 

3.  Inwards. 

4.  Outwards. 


566 


PARTICULAR  DISLOCATIONS. 


II.  Os  Calcis  and  Scaphoid  upon  the  Astragalus. 

1.  Backwards. 

2.  Inwards. 

3.  Outwards. 

III.  Cuboid  and  Scaphoid  upon  the  Os  Calcis  and  Astragalus. 

Forwards  and  upwards. 

IV.  Scaphoid. 

Forwards. 

Y.  Cuneiform  Bones. 

Forwards. 

1.  Dislocation  of  the  Astragalus. — This  may  occur  forwards,  back- 
wards, outwards,  and  inwards,  and  it  either  retains  its  horizontal 
position,  or  may  be  more  or  less  rotated  upon  its  axis  or  even  com- 
pletely reversed,  so  that  its  inferior  surface  will  look  directly  upwards. 

a.  Dislocation  forwards  is  caused  by  a fall  upon  the  foot  in  a position 

of  extension ; the  astragalus  is  forced  upon 
its  dorsum,  producing  a marked  promi- 
nence over  which  the  skin  will  be  tensely 
stretched ; the  leg  is  shortened,  and  the 
malleoli  approximated  nearer  to  the  bot- 
tom of  the  foot. 

b.  Dislocation  backwards  is  extremely 
rare ; and  is  caused  in  the  same  manner  as 
the  preceding,  only  the  foot  is  in  forced 
flexion  at  the  time  of  the  application  of  the 
injury:  the  astragalus  takes  a position 
posterior  to  the  joint  under  the  tendo- 
Achillis,  which  is  pushed  backwards,  and 
may  be  readily  perceived  in  its  new  posi- 
tion; the  instep  is  shortened,  and  the  heel 
elongated. 

c.  Dislocations  inwards  and  outwards 
(Fig.  517)  are  produced  by  the  force  acting 
upon  the  foot  when  it  is  abducted  or  -ad- 
ducted ; they  are  mere  varieties  of  the 
luxation  forwards. 

These  injuries  are  often  compound,  and 
attended  with  more  or  less  laceration  and 
bruising  of  the  soft  tissues  about  the  joint. 

Treatment. — In  simple  dislocation  of  the  astragalus,  efforts  should 
be  made  to  effect  its  reduction.  The  patient  should  be  thoroughly 
anaesthetized,  and  the  thigh  bent  at  right  angles  with  the  abdomen, 
and  the  leg  upon  the  thigh ; an  assistant  should  then  make  counter- 
extension from  the  lower  part  of  the  thigh,  while  another  takes  hold 
of  the  heel  and  instep,  or,  what  is  better,  applies  an  extending  lac  and 
firmly  draws  the  foot  downwards;  the  surgeon,  standing  by  the  limb, 
endeavors  to  press  the  astragalus  upwards  and  backwards  into  its 
place  with  his  thumbs  or  his  knee ; but  if  the  bone  has  an  inclination 
to  either  side,  the  pressure  should  be  exercised  first  in  such  a manner 


Fig.  517. 


Dislocation  of  the  astragalus 
outwards. 


DISLOCATION  OF  THE  TARSUS. 


567 


that  the  astragalus  may  assume  the  position  it  takes  in  forward  dislo- 
cation. While  the  pressure  is  being  made,  the  foot  should  be  adducted 
or  abducted,  according  as  the  one  or  other  of  these  positions  will  per- 
mit the  bone  to  slip  back  beneath  the  tibia.  Should  reduction  be 
impossible,  it  is  believed  by  the  majority 
of  surgeons  that,  in  order  to  save  the  FiS-  518- 

foot,  the  astragalus  ought  to  be  removed 
at  once. 

When  there  is  a wound  present,  and 
the  bone  can  be  felt  to  be  entirely  sepa- 
rated from  its  articular  connections  (Fig. 

518),  it  must  be  removed  immediately,  as 
it  then  acts,  as  any  foreign  body  would,  in 
causing  inflammation  and  suppuration 
of  the  joint,  which  will  lead  most  surely 
to  amputation  of  the  foot;  this  course  is 
altogether  the  safest  one,  as  in  a number 
of  the  recorded  cases  in  which  the  opera- 
tion had  been  performed  the  patients 
recovered  with  tolerably  good  limbs. 

Nekton's  opinion  is  that  in  simple  dis- 
location, even  of  the  astragalus,  the  re- 
duction ought  not  to  be  attempted,  but 
immediate  resection  had  recourse  to. 

This  view  is  in  opposition  to  the  prac- 
tice of  the  majority  of  surgeons;  and 
the  instances  of  successful  reduction  on 
record  are  sufficiently  numerous  to  in- 
duce the  surgeon,  in  all  cases  of  simple  dislocation,  to  try  manipulation 
before  resorting  to  the  knife. 

The  after-treatment  consists  in  giving  the  leg  and  foot  efficient 
support  with  splints,  and  to  meet  the  inflammation  with  appropriate 
antiphlogistics : when  suppuration  begins,  the  pus  should  have  a free 
issue  exteriorly. 

2.  Dislocation  of  the  Os  Calcis  and  Scaphoid  upon  the  Astragalus. — 
This  dislocation  may  occur  backwards,  inwards,  and  outwards;  the 
latter  bone  retaining  its  articular  connections  with  the  tibia.  In  dis- 
location backwards,  the  heel  is  elongated,  and  the  foot  in  front  of  the 
malleoli  correspondingly  shortened ; the  head  of  the  astragalus  can  be 
felt  under  the  skin  upon  the  top  of  the  foot,  lying  upon  the  scaphoid 
and  cuneiform  bones. 

The  luxation  inwards  is  marked  by  the  prominence  of  the  head  of 
the  astragalus  upon  the  outer  side  of  the  instep ; the  foot  is  usually 
in  a position  of  adduction,  with  its  external  border  resting  upon  the 
ground,  while  the  toes  turn  inwards  and  the  heel  outwards. 

The  astragalo- calcanean,  peroneo-calcanean,  and  tibio-calcanean  liga- 
ments are  more  or  less  torn,  and  usually  also  the  soft  parts  about  the 
foot,  particularly  over  the  head  of  the  astragalus,  which  may  perforate 
the  skin  and  be  visible  upon  the  side  of  the  foot. 

Dislocation  outwards  is  the  reverse  of  the  preceding.  The  head  of 


Compound  dislocation  of  tlie  astragalus 
inwards. 


568 


PARTICULAR  DISLOCATIONS. 


tlie  astragalus  will  form  a prominence  upon  the  inner  border  of  the 
foot,  which  is  forcibly  abducted  and  sometimes  greatly  rotated  upon 
the  leg;  when  the  os  calcis  is  completely  separated  from  the  astragalus, 
it  will  be  elevated  by  the  side  of  the  fibula,  and  the  leg  will  be  short- 
ened. Tbe  injury  is  almost  always  compound,  and  the  end  of  the 
fibula  and  head  of  the  astragalus  will  often  be  found  projecting  through 
the  wound  upon  the  inner  side  of  the  foot. 

Treatment. — The  reduction  should  be  attempted  by  making  exten- 
sion from  the  foot,  and  pressure  upon  the  bones  in  a direction  opposite 
the  displacement ; it  is,  however,  often  difficult,  if  not  impossible,  and 
may  then  demand  either  resection  or  amputation. 

3.  Dislocation  of  the  Cuboid  and  Scaphoid  upon  the  Os  Calcis  and 
Astragalus. — In  the  case  recorded  by  Liston  of  this  form  of  dislocation 
the  cuboid  and  scaphoid  were  thrown  upwards  and  forwards  upon  the 
os  calcis  and  astragalus,  caused  by  a heavy  stone  falling  upon  the  foot, 
which  was  twisted  in  such  a manner  as  to  resemble  club-foot.  The 
reduction  was  effected  by  making  extension  from  the  forepart  of  the 
foot,  and  the  patient  was  cured  in  five  weeks. 

4.  Dislocation  of  the  Scaphoid. — This  has  been  observed  to  occur  in 
several  cases ; the  bone  being  detached  from  its  connections  Avith  the 
cuneiform  only,  in  one  instance,  and  in  the  others  from  both  the  astra- 
galus and  cuneiform  bones,  and  displaced  forwards. 

Treatment. — Pressure  upon  the  scaphoid  with  the  thumb,  while  the 
forepart  of  the  foot  is  bent  downwards. 

5.  Dislocation  of  the  Cuneiform  Bones. — The  three  cuneiform  bones 
together  may  suffer  in  complete  luxation  forwards ; or,  Avhat  is  more 
common,  the  internal  cuneiform  may  be  completely  displaced,  and 
thrown  forwards  and  upwards  upon  the  tarsus  along  with  the  meta- 
tarsal bones.  The  symptoms  are  foreshortening  of  the  foot,  the  plantar 
surface  of  which  is  convex,  both  antero-posteriorly  and  transversely, 
and  turned  inwards;  the  proximal  ends  of  the  metatarsal  bones  form 
a ridge  upon  the  top  of  the  foot. 

Treatment. — Extension  from  forepart  of  the  foot  Avith  pressure  upon 
the  displaced  bones. 

Dislocation  of  the  Metatarsal  Bones. 

The  metatarsal  bones  may  be  dislocated  separately  in  any  direction 
by  crushing  force  being  brought  to  bear  upon  the  foot;  or  all  of  them 
together  may  be  thrown  forwards  and  upAvards  upon  the  tarsus ; the 
luxation  in  either  case  may  be  complete  or  incomplete.  In  the  former 
case  the  foot  will  be  shortened,  and  a ridge  Avill  be  formed  upon  the 
top  of  the  foot  by  the  proximal  extremities  of  the  displaced  bones; 
and  the  bottom  of  the  foot  will  present  a convex  instead  of  the  natu- 
ral concave  outline.  When  a single  bone  is  displaced,  its  upper  extre- 
mity will  cause  a recognizable  deformity  at  the  point  of  injury. 

Treatment. — Extension  from  the  forepart  of  the  foot,  and  counter- 
extension  from  the  lower  portion  of  the  leg  above  the  ankle,  combined 
with  pressure  upon  the  dislocated  bones. 


DISLOCATION  OF  THE  PHALANGES  OF  THE  TOES.  569 


Dislocation  of  the  Phalanges  of  the  Toes. 

Dislocation  of  the  phalanges  of  the  toes  may  occur  in  any  direction, 
and  be  complete  or  incomplete.  It  is  less  common  than  that  of  the 
phalanges  of  the  fingers,  and  more  often  compound. 

The  injury  is  caused  by  direct  violence  applied  to  the  toes.  Its 
treatment  should  be  conducted  upon  the  same  principles  laid  down  for 
dislocation  of  the  phalanges  of  the  fingers  already  explained. 


PART  Y. 

THE  MINOR  OPERATIONS  OF  SURGERY. 


CHAPTER  I. 

RUBEFACTION. 

Rubef action,  from  ruber,  “red,”  and  facio,  “I  make,”  is  the  result 
of  the  action  of  that  class  of  remedial  agents  called  rubefacients,  which 
have  the  property  of  causing  redness,  pain,  and  slight  swelling  of  the 
skin. 

The  number  of  substances  included  in  this  class  is  quite  large ; be- 
sides, there  are  several  mechanical  processes  that  have  been  employed 
to  obtain  this  modification  of  the  integuments. 

The  rubefacients  proper,  when  retained  too  long  upon  the  surface, 
produce  vesication ; while  the  mechanical  processes  under  ordinary 
circumstances  determine  rubefaction  only ; however,  should  the  fric- 
tion be  violent,  as  occurs  in  the  rapid  passage  of  a rope  through  the 
clenched  hand,  for  instance,  true  vesication  follows ; the  same  result 
may  also  accompany  energetic  shampooing. 

All  vesicants  are  necessarily  rubefacients;  and  may  often  be  used 
as  such  with  advantage  by  simply  regulating  the  period  of  their  con- 
tact with  the  skin. 

A peculiar  mode  of  producing  rubefaction  for  the  cure  of  neuralgia, 
chronic  rheumatism,  and  other  painful  and  long-standing  diseases  has 
been  in  vogue  in  China  and  other  eastern  countries  from  time  imme- 
morial. The  way  I have  seen  it  performed  is  this : The  patient  is 
stripped  naked,  and  the  operator,  generally  a barber,  commences  by 
striking  the  skin  over  the  painful  parts  lightly  with  the  tips  of  his 
fingers ; and  as  it  becomes  accustomed  to  the  new  impression,  and  also 
somewhat  numbed,  the  palms  of  the  hands  are  substituted  for  the  fin- 
gers, and  the  blows  fall  quicker  and  heavier,  in  regular  rhythm,  until 
the  affected  parts  are  quite  red  and  tender. 

The  Hindoo  operation  of  shampooing  is  also  a very  ancient  counter- 
irritant  process,  and  consists  in  the  forcible  pressure  of  the  muscles 
with  the  hands,  flagellations,  and  the  crackings  of  the  various  joints. 

The  massage  is  sometimes  of  real  utility  in  chronic  affections  of  the 
joints,  chronic  rheumatism,  false  anchylosis,  and  sprains. 

All  these  mechanical  means  will,  however,  be  of  limited  utility,  as 
possibly  their  only  action  is  to  blunt  the  sensibility  of  the  skin  by  the 
repetitions  of  monotonous  impressions  upon  the  nerves ; though  the 


KUBEFACTIOST. 


571 


counter-irritant  effect  of  the  determination  of  fluids  to  the  parts,  and 
the  stimulation  of  the  capillary  circulation  may  add  to  their  beneficial 
influence. 

Of  all  the  mechanical  methods,  friction  is  most  frequently  used  in 
the  treatment  of  surgical  disease.  It  is  of  two  kinds,  dry  and  moist; 
the  former  being  accomplished  with  the  palms  of  the  hands,  coarse 
towels,  or  stiff  brushes ; and  the  latter  with  a piece  of  flannel,  moist- 
ened with  stimulating  liquids. 

This  plan  is  indicated  in  the  same  class  of  cases  as  massage,  care 
being  taken  that  the  continuity  of  the  cuticle  be  not  disturbed. 

Rubefaction  is  most  generally  produced  by  the  use  of  sinapisms,  a 
name  given  to  a pasty  material  composed  principally  of  mustard,  and 
spread  upon  cotton  cloth  for  convenience  of  application. 

Mustard,  the  flour  of  the  seeds  of  the  Sinapis  nigra,  depends  for  its 
rubefacient  properties  upon  a volatile  oil  developed  by  the  reaction 
between  two  of  its  constituents,  myrosine  and  myronic  acid,  in  the 
presence  of  water,  the  temperature  of  which,  to  obtain  the  most  active 
cataplasm,  should  be  inside  of  212°  Fahr. 

Some  persons  are  in  the  habit  of  employing  vinegar  instead  of  water, 
but  the  practice  is  wrong,  as  the  former  fluid  materially  interferes  with 
the  production  of  the  volatile  oil.  Strong  acids  and  the  alkalies  have 
the  same  effect. 

If  it  is  desirable  to  increase  the  activity  of  the  mustard,  red  pepper, 
garlic,  or  cantharides  in  powder,  may  be  added  to  it;  on  the  other  hand, 
to  diminish  its  activity  it  may  be  incorporated  with  powdered  flaxseed 
or  bread  crumb. 

The  time  required  for  a sinapism  to  produce  a rubefacient  will 
depend  upon  the  thickness  and  susceptibility  of  the  skin,  and  the  age 
of  the  patient.  A thin  skin  with  its  nutritive  processes  going  on 
actively,  will  show  the  effects  of  a rubefacient  in  a much  shorter  time 
than  one  in  which  the  contrary  conditions  obtain,  as  in  cases  of 
paralysis,  where  several  hours  will  elapse  before  any  action  is  mani- 
fested, if  it  is  manifested  at  all.  It  sometimes  happens,  however,  in 
these  paralytic  patients  that  a sinapism  may  remain  on  for  a long  time  ; 
and  when  it  is  raised,  no  effect  will  be  observed  upon  the  skin,  nor 
will  the  person  complain  of  any  pain  or  sensation  in  the  part,  yet  at 
the  end  of  some  days  vesication  and  even  mortification  may  result. 

As  a general  rule  it  may  be  stated  that  less  time  is  required  to  pro- 
duce rubefaction  in  children  than  in  women,  and  in  these  than  in  men. 

Under  ordinary  circumstances,  sinapisms  made  with  cool  wrater 
i should  not  be  permitted  to  remain  in  contact  with  the  skin  longer  than 
one  hour,  though  in  the  special  cases  mentioned  above  a much  longer 
or  a much  shorter  period  may  be  proper. 

The  best  guide,  in  all  cases,  as  to  the  proper  time,  where  the  nervous 
system  is  in  its  normal  state,  is  the  sensations  of  the  patients;  though 
the  redness  of  the  skin  will  be  of  some  assistance,  as  it  enables  us  to 
judge  of  the  degree  of  rubefaction. 

After  the  desired  effect  has  been  produced  the  sinapisms  should  be 
promptly  removed,  and  the  surface  of  the  skin  cleansed  by  allowing 
a little  warm  water  to  flow  upon  it.  If  there  is  much  pain,  a small 


572 


RUBEFACTION. 


quantity  of  ether  may  be  allowed  to  fall  upon  the  parts,  guttatim. 
which  will  assuage  it  immediately.  Any  soreness  or  tenderness  will 
be  best  met  by  the  application  of  lint  dipped  in  glycerine,  oil  of  sweet 
almonds,  or  olive  oil.  Ointments  containing  the  ordinary  narcotics, 
opium,  belladonna,  or  stramonium  will  answer  the  same  purpose. 

When  the  continuous  counter-irritant  effects  of  a sinapism  are  re- 
quired, it  should  be  moved  from  point  to  point  every  few  minutes  to 
avoid  too  much  action  in  one  place,  but  yet  not  over  too  great  an 
extent  of  surface ; otherwise,  unpleasant  constitutional  disturbance 
may  ensue. 

Under  certain  circumstances,  it  may  be  important  to  obtain  rube- 
faction  speedily ; then  the  volatile  oil  of  mustard  dissolved  in  alcohol 
in  the  proportion  of  one  part  by  weight  of  the  former  to  twenty  of 
the  latter  may  be  used,  rubbing  it  upon  the  skin  with  a piece  of  flannel ; 
its  effects  will  be  produced  in  three  or  four  minutes.  Other  articles, 
as  ammonia,  will  produce  the  same  effects. 

Urtication  is  a sort  of  rubefaction  produced  by  striking  the  skin 
with  a bunch  of  nettles  ( Urtica  dioitica),  or  rubbing  upon  it  an  oint- 
ment containing  the  common  cowhage  ( Doliclios  pruriens). 

In  narcotic  poisoning,  flagellation  with  nettles  was  formerly  em- 
ployed; but  its  use  is  now  entirely  abandoned. 

Sinapisms  justly  occupy  a high  position  in  the  esteem  of  the  people 
at  large  as  a remedy  of  superior  merit  in  numerous  ailments,  while 
the  profession  is  equally  as  decided  upon  their  virtues  in  numerous 
diseases  coming  daily  under  notice. 

They  are  employed  as  a general  excitant  in  syncopal  attacks, 
shock,  or  severe  concussion  from  injuries,  and  in  nervous  depression: 
as  a local  excitant  to  recall  retrocedent  eruptions  and  inflammations, 
as  in  measles,  smallpox,  gout,  and  rheumatism ; as  a counter-irritant 
in  inflammatory  diseases  of  the  brain,  and  of  the  organs  contained 
within  the  thorax  and  abdomen ; and  to  relieve  various  painful  affec- 
tions from  other  sources. 

Sinapisms  form  the  favorite  and  safest  counter-irritant  in  the  dis- 
eases of  children,  when  blisters  are  contra-indicated  by  the  debility  of 
the  patient,  or  the  extreme  sensibility  of  the  skin.  W e should  be 
careful  in  these  cases  not  to  let  them  remain  on  the  person  of  the 
child  until  constitutional  disturbance  results  from  the  local  stimula- 
tion, and  thereby  do  more  injury  than  can  be  counterbalanced  by  the 
good  done  by  their  counter-irritant  effect. 

For  speedy  rubefaction  Dr.  Corrigan  recommends  the  instrument 
seen  in  Fig.  519.  It  consists  of  a thick  iron-wire  shank,  about  two 

inches  Ions;,  inserted  in  a small 
wooden  handle,  having  on  its 
extremity,  which  is  slightly 
curved,  a disk  or  button  of 
iron,  a quarter  of  an  inch 
thick,  and  half  an  inch  in 
diameter. 

To  use  the  instrument,  it 
is  necessary  to  hold  the  button 
over  the  flame  of  a small  spirit-lamp,  keeping  the  forefinger  ot  the 


Fig.  519. 


Corrigan's  button  cautery. 


VESICATION. 


573 


ihand  holding  the  instrument  at  the  distance  of  about  half  au  inch 
from  the  button.  As  soon  as  the  finger  feels  uncomfortably  hot,  the 
instrument  is  ready  for  us,e;  and  the  time  required  for  heating  it  to 
this  degree  is  only  about  a quarter  of  a minute.  It  is  applied  as 
quickly  as  possible,  the  skin  being  tipped  successively  at  intervals  of 
half  an  inch  over  the  affected  part  as  lightly  and  as  rapidly  as  pos- 
sible. 

| ' 


CHAPTER  II. 

VESICATION. 

Vesication,  from  vesica,  a "bladder,”  or  “blister,”  is  the  action  of 
that  class  of  remedies  called  vesicants,  which  cause  inflammation  of 
the  skin,  and  an  effusion  of  serum  beneath  the  cuticle,  forming  little 
bladders  or  vesicles. 

The  local  inflammatory  action,  with  its  accompanying  derivative 
effects  and  constitutional  excitation,  does  not  constitute  the  whole 
therapeutical  influence  of  vesicants ; for  along  with  this,  there  is  an 
effusion  of  fibrinous  serosity  from  the  blood,  which  confers  upon  them 
an  important  value  as  depletants. 

The  extent  to  which  this  effusion  sometimes  takes  place  was  shown 
in  a case  which  came  under  my  care  some  months  since.  The  patient 
had  an  ordinary  blister  applied  upon  the  abdomen,  over  night;  and 
the  following  morning  it  was  removed,  displaying  a large  vesicle  filled 
•with  a pale,  yellowish,  jelly-like  mass,  a quarter  of  an  inch  in  thick- 
ness, which,  with  every  movement  of  the  patient,  presented  that  tre- 
mulous motion  peculiar  to  jellies.  Its  removal  was  followed,  in  a few 
hours,  by  another  layer  of  the  same  material,  though  thinner,  and  it 
was  some  days  before  the  serosity  ceased  to  concrete  spontaneously 
upon  the  blistered  surface. 

: Some  of  the  rubefacients  already  spoken  of  will  vesicate  if  kept 
-ipon  the  surface  a sufficient  period,  yet  there  are  other  articles  more 
Especially  employed  for  this  peculiar  purpose,  and  they  are  drawn 
Tom  all  three  of  the  kingdoms  of  nature. 

Of  the  physical  agents  heat  has  been  employed  as  a vesicant  in 
several  ways;  yet  it  is  not  so  readily  manageable  as  to  recommend 
tself  as  a general  method;  for  though  its  action  is  speedy  and  cer- 
tain, the  fear  of  its  causing  an  eschar,  and  the  pain  of  its  application,, 
will  restrict  its  use  to  a very  limited  number  of  cases. 

A compress  folded  several  times,  then  dipped  into  boiling  water,, 
md  applied  to  the  skin,  will  produce  quick  vesication. 

The  head  of  a hammer,  or  the  flat  cautery  iron,  held  for  a few 
noments  in  boiling  water  and  laid  upon  the  surface,  will  also  give 
ise  to  the  same  result. 

Sir  Anthony  Carlisle  laid  over  the  skin  a wet  cloth,  and  passed 
ver  it  a flat  cautery-iron,  brought  to  a dull  red  heat. 


574 


VESICATION. 


It  has  been  recommended  in  collapse,  attended  with  great  insensi- 
bility of  the  skin,  to  produce  a blister  immediately  by  placing  a piece 
of  tissue-paper,  saturated  with  alcohol  or  spirits  of  turpentine  upon 
the  surface,  and  set  fire  to  it.  A jet  of  steam,  from  the  spout  of  a 
vessel  containing  boiling  water,  has  been  suggested  with  a similar 
view. 

We  have  already  spoken,  at  page  69,  of  the  liquor  ammonise  of  the 
Pharmacopoeia  as  a vesicant,  and  its  mode  of  application.  A watch- 
glass  case  will  answer  the  same  purpose  as  the  lid  of  a box  there 
mentioned.  Place  a round  piece  of  muslin,  a little  smaller  than  the 
glass,  and  saturated  with  liquor  ammonia,  upon  the  skin,  previously- 
cleared  of  hair,  and  then  cover  it  with  the  crystal.  In  half  a minute 
or  a minute  a red  areola  will  be  seen  to  surround  the  margin  of  the 
glass,  when  it  should  be  removed,  and  an  appropriate  dressing  applied 
to  the  blister. 

When  the  ammonia  is  incorporated  with  fatty  matters,  the  vesicat- 
ing ammoniacal  ointment  of  Dr.  Gondret  is  formed.  “ The  amended 
formula  is  as  follows : Take  of  lard  32  parts ; oil  of  sweet  almonds 
2 parts ; melt  them  together  by  the  gentle  heat  of  a candle  or  lamp, 
and  pour  the  mixture  into  a bottle  with  a wide  mouth.  Then  add 
17  parts  of  solution  of  ammonia  of  25°,  and  mix,  with  continued  agi- 
tation, until  the  whole  is  cold.  The  ointment  must  be  preserved  in  a 
bottle  with  a ground  stopper,  and  kept  in  a cool  place.” — U.  S.  D. 

This  ointment  is  applied  by  spreading  it  upon  muslin,  and  when 
freshly  prepared  it  will  vesicate  in  from  five  to  ten  minutes.  The 
application  will  be  more  accurate,  and  the  ammonia  prevented  from 
evaporating,  by  using  a shallow  pill-box  lid  instead  of  the  muslin. 

It  will  be  a useful  precaution,  in  using  these  ammoniacal  mixtures, 
to  protect  the  parts  surrounding  the  place  to  be  blistered,  by  adhesive 
plaster,  which  may  be  laid  over  them,  having  a hole  of  the  proper  size 
cut  into  it,  to  expose  that  portion  of  the  skin  to  which  the  vesicant  is 
to  be  applied. 

The  vegetable  kingdom  furnishes  from  the  two  orders,  Ranuncu- 
laceae  and  Euphorbiacese,  many  active  vesicants,  among  which  are 
several  species  of  the  Ranunculus,  or  crowfoot,  which,  before  the  intro- 
duction of  the  Spanish  flies  into  use,  were  much  employed  as  vesicants. 

The  knowledge  of  the  powerful  rubefacient  and  epispastic  proper- 
ties of  these  plants  may,  on  occasions,  be  serviceable  to  the  country 
practitioner.  Nearly  the  same  qualities  are  possessed  by  the  bulb  of 
the  Indian  turnip. 

Mezereon-bark  is  also  a slow  vesicant,  and  is  frequently  used  by 
German  surgeons  for  this  purpose.  For  the  application  of  this.  Che- 
lius  directs  that  “a  piece  of  the  bark  an  inch  and  a half  long  and  the 
same  wide  should  be  soaked  eight  or  ten  hours  in  vinegar  or  water, 
after  which  it  is  to  be  applied  with  its  smooth  surface  next  to  the  skin, 
generally  upon  the  arm,  at  the  insertion  of  the  deltoid  muscle,  and 
covered  with  a piece  of  oiled  silk,  compress,  and  roller,  to  keep  it 
close.  After  ten  or  twelve  hours,  when  the  bandage  is  removed,  it 
the  skin  be  sufficiently  inflamed,  a piece  of  oiled  silk  is  to  be  applied 
on  the  inflamed  part  and  fastened  with  compress  and  bandage ; but  it 


VESICATION. 


575 


(the  first  application  have  not  been  effective,  a second  piece  of  the  bark 
must  be  applied.  About  the  second  or  third  day  a new  piece  of  bark 
is  put  on,  the  skin  rises,  and  a serous  fluid  exudes.  The  part  must 
be  cleansed  daily  with  warm  water  or  milk;  and  if  the  inflammation 
be  very  great,  it  must  be  rubbed  with  warm  milk  and  bound  up  with 
some  mild  ointment.” 

Croton  oil,  obtained  by  expression  of  the  seeds  of  the  Croton  tig- 
lium,  is  an  excellent  vesicant.  Its  operation  is  not  at  all  painful,  nor 
actively  depletive,  but  mildly  counter-irritant.  For  these  reasons  it 
recommends  itself  highly  to  the  notice  of  the  practitioner  in  those 
cases  of  disease  where  long-continued  counter-irritation  has  been  found 
useful.  The  oil  may  be  applied  to  a large  extent  of  surface,  without 
any  fear  from  constitutional  disturbance  or  of  its  manifesting  its  spe- 
cific action  upon  the  intestines. 

It  may  be  used  pure,  or  diluted  in  various  degrees  with  olive  oil, 
and  rubbed  into  the  skin  with  a piece  of  flannel,  or  the  point  of  the 
finger  protected  with  oiled  silk. 

Two  or  three  applications  will  be  necessary  to  obtain  the  desired 
result,  which  consists  in  the  production  of  a crop  of  vesicles,  at  first 
containing  a clear  fluid,  but  in  a little  while  this  becomes  opaque  and 
yellowish.  The  skin  beneath  the  vesicles  is  changed  to  a red  color, 
accompanied  with  a sensation  of  stinging  and  swelling  of  the  parts. 

After  two  or  three  days  the  pustules  dry  up,  the  irritation  disap- 
pears, and  new  cuticle  is  formed. 

The  application  of  the  oil  in  this  manner  requires  two  days  or  more 
to  produce  the  effect,  in  consequence  of  the  escape  of  crotonic  acid, 
upon  which  its  efficacy  depends.  To  avoid  this,  Bouchardat  suggested 
to  M.  Chomel  a formula  containing  one  part  of  the  oil  incorporated 
with  four  parts  of  lead  plaster,  spread  upon  linen  in  the  same  manner 
as  adhesive  plaster.  These  proportions  may,  however,  be  varied 
according  to  circumstances.  This  plaster,  worn  upon  the  person 
twenty-four  hours,  will  produce  an  abundant  eruption  of  vesicles. 

In  employing  preparations  containing  croton  oil,  care  should  be 
taken  that  the  patient’s  hands  do  not  come  in  contact  with  the  parts, 
else  some  of  the  oil  will  be  transferred  to  the  skin  of  the  eyelids, 
scrotum,  or  other  localities,  and  thus  produce  swelling  of  them,  and 
an  annoying  sensation  of  burning. 

The  application  of  a dressing  of  glycerine  or  cold  water  will  relieve 
hese  unpleasant  accidents. 

The  animal  kingdom  supplies  from  among  the  coleopterous  insects 
several  vesicating  species,  of  which  only  two — the  cantharis  vesica- 
;oria,  or  Spanish  fly,  and  the  cantharis  vittata,  or  potato-fly — have 
been  introduced  into  the  Pharmacopoeia  of  the  United  States,  and  it 
.s  of  these  that  our  officinal  preparations  are  made. 

The  cerate  of  Spanish  flies  ( Ceratum  cantharidis)  is  the  common 
blistering  plaster  of  the  shops;  it  should  be  spread  upon  leather, 
.hough  linen,  or  even  paper,  will  answer  the  purpose  when  that  is  not 
o be  had.  In  applying  the  plaster,  the  skin  is  to  be  cleansed  of  hairs 
tnd  well  rubbed  with  vinegar  or  oil,  which  will  materially  facilitate 
he  action  of  the  vesicant.  It  is  recommended  that  the  surface  of  the 


57  6 


VESICATION. 


blister  be  covered  with  oil  or  a layer  of  simple  cerate,  oiled  paper,  or, 
what  is  better,  a piece  of  very  thin  tissue-paper  or  gauze.  These 
interposed  substances  will  prevent  the  particles  of  the  flies  sticking 
to  the  skin  and  producing  strangury.  With  the  same  view,  the  late 
Dr.  Joseph  Ilartshorne  was  in  the  habit,  in  cases  where  he  appre- 
hended such  a result,  of  directing  four  grains  of  opium  and  twenty  of 
camphor  to  be  mixed  with  the  cerate  of  a blister  of  large  size;  an 
ethereal  solution  of  camphor  may  also  be  used,  brushed  over  the  sur- 
face of  the  plaster  before  it  is  applied. 

The  decoction  of  the  uva  ursi,  in  the  dose  of  a wineglassful  every 
hour  during  the  application  of  the  epispastic,  is  also  highly  recom- 
mended as  a preventive  of  strangury. 

The  time  the  blister  should  be  kept  on  depends  upon  the  object 
had  in  view,  the  general  sensibility  and  age  of  the  patient.  If  simple 
vesication  is  desired,  or  what  the  French  call  a “flying  blister,"  the 
cerate  should  remain  on  a shorter  time  than  if  a permanent  one  is 
required,  or  one  destined  to  be  kept  open  a long  time ; in  very  sus- 
ceptible subjects,  and  particularly  in  children,  great  care  is  necessary 
that  the  irritation  do  not  extend  too  far,  as  mortification  of  the  integu- 
ments has  happened  in  such  patients.  The  safest  plan  in  these  cases 
is  to  keep  the  plaster  on  only  until  the  skin  is  bright  red,  when  a 
poultice  must  be  applied,  which  will  raise  a vesicle  in  a few  hours. 

The  average  time  for  the  retention  of  a blister  upon  the  skin  in  an 
adult  may  be  stated  to  be  four  hours ; the  skin  of  the  scalp  being 
much  thicker  than  it  is  in  other  localities,  will  require  a longer  time 
for  the  plaster  to  vesicate — from  twenty  to  twenty-four  hours. 

The  mode  of  dressing  the  blistered  surface  depends  also  upon  the 
object  had  in  view  by  the  practitioner;  if  it  is  not  intended  to  keep 
up  a discharge,  the  vesicle  must  be  punctured  with  a lancet,  or  the 
points  of  the  scissors,  and  the  serum  permitted  to  escape,  when  it  may 
be  dressed  with  a cerated  cloth,  an  emollient  poultice,  or,  what  is 
more  common  in  domestic  practice,  with  a cabbage  leaf;  in  two  or 
three  days  the  irritation  will  have  subsided;  and  in  four  or  six  more  the 
surface  will  be  healed.  Dr.  Maclagan  recommends  a dressing  of  raw 
cotton  after  the  serum  is  evacuated,  which  is  to  be  renewed  as  often  as 
it  becomes  soaked,  care  being  taken  not  to  pull  off  the  cuticle  in  the 
operation.  If  a permanent  blister  is  required,  after  the  evacuation  of 
the  serum,  the  cuticle  is  to  be  removed,  and  a dressing  of  basilicon 
ointment,  or  some  other  stimulating  substance  is  to  be  applied  to  the 
raw  surface,  which  will  prevent  its  healing,  and  increase  its  secretion. 

It  has  been  suggested,  when  the  patient  is  comatose,  to  tear  the  cuti- 
cle off  suddenly,  so  that  the  sudden  impression  of  the  air  upon  the 
delicate  nervous  loops  of  the  surface  below  may  produce  a salutary 
shock  to  the  nervous  system,  tending  to  rouse  the  dormant  energies. 

Another  mode  of  using  the  cantharides  is  under  the  form  of  can- 
tharidal  collodion,  prepared  by  dissolving  gun-cotton  in  an  ethereal 
solution  of  cantharidin,  the  active  principle  of  Spanish  flies.  It  pos- 
sesses the  advantages  over  the  cerate  of  keeping  a long  time  without 
change,  and  of  being  more  prompt  in  its  action  ; it  should  be  applied 
to  the  surface,  prepared  as  in  the  former  case,  with  a camels  hair 


CAUTERIZATION. 


577 


brush,  and  covered  with  a piece  of  oiled  silk.  Cantharidin  is  also 
incorporated  with  wax,  and  spread  in  a very  thin  layer  upon  fine 
waxed  cloth,  silk  or  paper,  constituting  the  blistering  cloth,  blistering 
paper,  vesicating  taffetas,  etc.  of  the  shops. 

When  there  is  too  much  irritation  of  the  blistered  surface,  and  false 
membrane  is  formed  upon  it,  great  advantage  will  accrue  from  the  use 
of  emollient  poultices  ; while  severe  pain  may  be  controlled  by  employ- 
ing the  watery  solution  of  opium,  applied  by  a piece  of  soft  old  linen. 
Care  should  be  taken  that  the  suppurative  action  be  not  continued  so 
long  as  to  give  rise  to  the  formation  of  a thick  and  knotty  cicatrix. 
If  the  discharge  becomes  profuse  and  fetid,  poultices  containing  La- 
barraque’s  solution,  finely-powdered  charcoal,  or  creasote  may  be  laid 
upon  the  part. 

When  it  is  desired  to  stop  the  drain,  an  ointment  consisting  of  equal 
parts  of  simple  cerate  and  the  cerate  of  the  subacetate  of  lead  will  be 
found  the  most  efficient  application  for  this  purpose. 

Blisters  are  sometimes  produced  for  other  purposes  than  counter- 
irritation, as  when,  from  any  cause,  as  the  excessive  irritability  of  the 
stomach,  etc.,  medicines  cannot  be  swallowed,  their  introduction  into  the 
system  may  be  effected  by  simply  placing  them  upon  the  denuded  cutis, 
constituting  what  has  been  called  the  endermic  method  of  medication. 

In  this  way  morphia,  quinine,  and  other  remedies  may  be  employed  ; 
they  should  be  finely  levigated  or  powdered,  so  as  to  contain  no  gritti- 
ness to  irritate  the  surface ; and,  if  too  active,  may  be  incorporated  with 
some  fatty  or  gelatinous  matter.  It  is  always  better,  when  it  can  be 
accomplished,  to  simply  make  an  aperture  in  the  vesicle,  and  slip  the 
medicine  into  it,  so  that  the  air  may  not  come  in  contact  with  the  cutis, 
which  diminishes  its  absorbent  power ; or  to  raise  the  cuticle,  and, 
after  sprinkling  the  powder  upon  the  cutis,  lay  it  down  again. 

Should  the  remedies  act  energetically  upon  the  system,  their  absorp- 
tion may  be  arrested  by  making  compression  upon  the  blistered  sur- 
face. 


CHAPTER  III. 

CAUTERIZATION. 

Cauterization  is  the  process  by  which  the  vitality  of  the  tissues 
is  destroyed  by  heat  or  certain  chemical  agents,  the  former  being  called 
the  actual  cautery,  and  the  latter  potential  cauteries.  They  act  by  de- 
composing the  tissues,  and  thereby  destroying  the  life  of  the  part ; 
the  new  combination  produced,  generally  dark-colored,  and  technically 
named  the  eschar , now  becomes  foreign  matter,  and  is  ultimately  sepa- 
rated from  the  living  tissues  beneath  by  inflammatory  action. 

1.  Actual  cauterization  may  be  produced  by  several  methods,  which 
we  shall  consider  seriatim. 

The  red-hot  iron  was  much  employed  by  the  ancients  as  a cautery, 


578 


CAUTERIZATION. 


and  highly  lauded  by  Hippocrates.  It  continued  to  be  used  freely  in 
numerous  surgical  diseases  for  centuries.  In  later  times,  Pouteau, 
Dupuytren,  and  the  elder  Larrey  were  its  warm  admirers,  but  at  present 
surgeons  have  very  much  restricted  the  limits  of  its  application. 

The  effects  of  the  actual  cautery  upon  the  body  are : the  production 
of  moderate  pain,  and  a black  eschar  at  the  point  of  its  application, 
which  is  subsequently  thrown  off',  leaving  a suppurating  surface 
beneath ; there  is  also  a decided  impression  made  upon  the  nervous 
system  not  observed  to  follow  potential  cauterization,  whose  influence 
is  more  local.  The  supervening  inflammation  produces  a local  deriva- 
tion and  a general  excitation,  which  latter  may  amount  to  fever  if  not 
checked  by  appropriate  measures.  It  is  important  to  remember  that  if  the 
cauterization  is  only  intended  to  destroy  the  tissues,  the  local  inflam- 
mation ought  to  be  restricted  at  once,  if  possible,  to  that  degree  neces- 
sary to  throw  off  the  eschar ; on  the  contrary,  if  a powerful  derivative 
effect  is  desired,  as  in  ulceration  of  the  cartilages,  for  instance,  Pott’s 
disease,  and  coxalgia,  the  inflammation  should  be  permitted  to  progress 
within  safe  limits;  and  hence  it  is,  that  repeated  touching  of  the  issue 
with  the  hot  iron,  when  the  inflammation  decreases,  is  so  much  more 
beneficial  and  effective,  in  these  cases,  by  renewing  the  counter-irrita- 
tive action,  than  any  other  sort  of  application  for  this  purpose. 

The  wound  remaining  after  the  separation  of  the  eschar  heals  up 
rapidly,  though  a cicatrix  of  a size  proportioned  to  the  extent  of  the 
slough  always  remains. 

The  ancients  employed  irons  of  various  shapes  and  made  of  different 
metals,  upon  the  supposition  that  the  action  of  the  latter  was  dissimi- 
lar ; but  as  heat  is  the  efficient  agent,  it  matters  very  little  of  what  metal 
the  cautery  is  made;  though  iron,  or,  better  still,  steel,  is  the  material 
now'  used;  steel  changes  color  with  the  different  degrees  of  temperature, 
so  that  the  surgeon  is  enabled  very  wrell  to  decide  by  color  alone  how 
far  the  metal  is  heated. 

The  cautery  is  provided  with  a vrooden  handle,  to  which  irons  of 
different  shapes  may  be  attached  by  means  of  a socket  and  thumb- 
screw ; these  various  forms  are  very  well  shovm  in  the  annexed  wood- 
cut  (Fig.  520).  The  conical  cautery  is  convenient  for  cauterizing  in 


Fig.  520. 


cavities,  as  the  neck  of  the  uterus,  the  walls  of  the  vagina  being  pro- 
tected by  a speculum  previously  introduced  ; the  narrow  pointed  iron 


CAUTERIZATION'. 


579 


will  enable  the  surgeon  to  reach  the  mouth  of  the  bleeding  vessel  at 
the  bottom  of  a wound ; and  in  obstinate  hemorrhage  from  a stump 
which  had  resisted  all  other  means,  I employed  this  cautery  with  suc- 
cess. The  nummular  cautery  having  a broad  surface  is  used  to  make 
issues,  while  the  one  with  a hatchet-shaped  extremity  furnishes  a form 
by  which  the  cauterization  may  be  restricted  to  narrow  lines. 

Should  the  proper  cautery  iron  not  be  at  hand,  an  iron  rod,  or  spike 
of  proper  size,  will  answer  well  enough. 

The  pain  of  the  actual  cautery  will  depend  in  a great  measure  upon 
the  degree  of  heat  of  the  iron,  a white  heat  being  much  less  painful 
than  if  the  iron  be  heated  to  redness  only.  In  forming  a thick  eschar, 
; it  is  advisable  to  re-apply  the  iron  brought  to  a white  heat,  for  five  or 
six  seconds  each  time,  rather  than  let  it  cool  in  contact  with  the 
tissues ; for  then  it  sticks  to  the  part,  and,  if  forcibly  withdrawn,  may 
bring  the  slough  with  it,  and  thus,  perhaps,  renew  a hemorrhage  it 
was  designed  to  check. 

■ The  point  at  which  the  cautery  is  to  be  applied  must  be  wiped  dry, 
that  the  heat  may  not  be  absorbed  in  converting  the  secretions  into 
steam;  and  care  should  be  taken  also  that  the  cauterization  be  not 
performed  over  the  tracks  of  large  bloodvessels  and  nerves.  If  it 
should  be  necessary  to  protect  the  adjacent  parts,  a cloth  wrung  out 
of  cold  water  may  be  laid  upon  them;  or,  in  narrow  passages  and 
fistulous  canals,  a metallic  tube,  or  one  prepared  with  an  ordinary 
visiting  card,  will  secure  their  walls  from  contact  with  the  iron. 

A common  hammer  dipped  in  boiling  water  and  kept  in  contact 
with  the  skin  ten  or  twelve  seconds  will  produce  an  eschar,  and  has 
been  recommended  as  a general  excitant  in  suspended  animation  from 
prolonged  immersion  in  water,  and  from  poisoning  by  prussic  acid 
;and  its  compounds.  Cloths  wrung  out  of  boiling  water  have  been 
^employed  in  the  same  manner ; they  will  produce  an  eschar  in  from 
'eight  to  ten  minutes. 

Various  combustible  bodies  have  been  used  as  cauterizing  agents, 
such  as  phosphorus  in  small  grains  laid  upon  the  skin  and  then  set 
fire  to.  The  pain  produced  is  intense,  and  the  contact  of  the  phos- 
phoric acid  formed  with  the  wound  causes  an  almost  intolerable  burn- 
ing sensation.  Camphor  and  gunpowder  have  had  their  advocates,, 
but  this  method  of  cauterization  is  now  properly  abandoned. 

The  actual  cautery  may  be  employed  with  advantage  as  a haemos- 
tatic in  sealing  up  the  mouths  of  bleeding  vessels  in  wounds  or  opera- 
tions in  persons  laboring  under  the  hemorrhagic  diathesis;  to  check 
hemorrhage  following  the  extraction  of  teeth ; to  arrest  the  progress 
if  caries ; as  a counter-irritant  in  chronic  articular  affections  and 
ilceration  of  the  cartilages  in  angular  curvature  of  the  spiue ; and  in 
poxalgia. 

The  galvanic  cautery  was  first  proposed  by  M.  Heider,  of  Vienna* 
n 1844,  and  afterwards  tried  in  France  by  Sedillot,  Amussat,  and 
Velaton,  without,  however,  deriving  the  advantages  claimed  for  it 
iy  its  advocates.  In  1854,  M.  Middeldorpff,  believing  that  the  diffi- 
;ulty  in  the  way  of  its  practical  use  resulted  from  the  waut  of  a proper 
)attery  and  suitable  instruments,  brought  it  prominently  into  notice 


580 


CAUTERIZATION. 


again  with  improved  appliances  which  rendered  the  application  of  the 
cautery  convenient  and  effective ; and  since  that  time  it  has  been  used 
by  surgeons  generally  with  more  or  less  success  in  the  treatment  of 
those  diseases  in  which  the  actual  cautery  is  indicated. 

M.  Middeldorpff  employs  a Groves’  battery  of  four  couples,  to  each 
pole  of  which  a conductor  is  atttached  two  yards  long,  and  composed  of 
eight  copper  wires  wrapped  in  silk  (Fig.  521);  the 
distal  extremities  of  the  two  conductors  are  con- 
nected with  the  tip  of  the  ivory  handle  of  the 
cautery  by  thumb-screws  (A  A)  making  a con- 
nection in  this  manner  with  two  insulated  wires, 
E,  which  run  through  the  handle  and  terminate 
beyond  it  in  two  sockets  furnished  with  two 
thumb-screws,  F F,  to  receive  the  different  forms 
of  the  cauteries;  upon  the  side  of  the  handle 
there  is  a little  button  (B)  by  pressing  upon 
which  the  connection  is  instantly  broken,  and  the 
electric  current  ceases  to  flow  through  the  wires. 


The  armatures  of  the  ivory  or  ebony  handle  are  variously  formed; 
the  olive-shaped  and  nummular  cauteries  consist  of  a platinum  wire 
wrapped  spirally  around  grooved,  thin,  and  hollow  porcelain  shells, 
which  are  rendered  incandescent  by  the  heat  of  the  wire ; they  are 
intended  for  the  cauterization  of  some  extent  of  surface,  as  in  making 
issues,  destroying  the  tissue  about  the  neck  of  the  uterus,  &c.  (Figs. 
522,  528.) 

The  hatchet-shaped  and  conical  cauteries  are  formed  of  narrow 
strips  of  platinum  bent  upon  themselves  in  different  ways. 

Galvanic  setons  are  formed  of  platinum  wires  of  different  sizes, 
which  are  drawn  through  fistulous  canals,  or  the  tissues  we  propose 
to  cauterize  by  straight  or  curved  needles.  Mr.  Marshall,  of  London, 
who  has  paid  a good  deal  of  attention  to  this  subject,  devised  the 
instrument  seen  in  the  annexed  wood-cut  (Fig.  524),  for  cauterizing  the 
interior  of  serous  or  fungous  granulations. 

The  galvanic  porte-ligature  (Fig.  525,  5)  is  formed  of  a platinum 


Fig.  521. 


CAUTERIZATION. 


581 


wire  passing  through  two  short  metallic  tubes  borne  upon  a handle,  in 
such  a manner  as  to  form  a loop,  which  is  placed  around  the  base  of 


Fig.  524. 


the  part  to  be  divided,  and  drawn  tight  by  two  handles  attached  to 
the  extremities  of  the  wire;  this  instrument  cuts  the  tissues  perfectly. 

M.  Rumkorff  has  substituted  for  Groves’  battery  employed  by 
Middeldorpff  that  of  Bunsen,  seen  in  the  adjoining  illustration  (Fig. 


Fig.  525. 

1 2 3 4 5 


525).  With  this  apparatus,  composed  of  six  elements,  the  desired 
amount  of  heat  can  be  readily  obtained.  Figs.  1,  2,  3,  T,  and  5 show 
the  variously  shaped  cauteries  described  above. 

In  applying  these  cauteries,  they  are  to  be  placed  in  contact  with 
the  part  cold ; and  then  the  galvanic  current  may  be  established  and 
continued  sufficiently  long  to  obtain  the  object  in  view;  ordinarily, 
from  five  to  fifteen  minutes  will  suffice  to  procure  moderate  cauteri- 
zation. 

2.  Potential  cauterization  is  produced  by  various  chemical  agents, 
each  possessing  some  peculiarity  in  its  mode  of  action  or  degree  of 
activity  and  manageability.  That  a caustic  may  act  properly,  a cer- 
tain amount  of  moisture  is  required ; if  there  is  too  much,  the  liquid 
will  flow  over  the  adjacent  surface,  or  combining  with  the  caustic  will 


582 


CAUTERIZATION. 


form  a protecting  layer  between  it  and  the  parts  beneath ; and  hence 
it  is  necessary,  in  open  wounds,  sores,  &c.,  where  the  secretion  is 
abundant,  to  cleanse  them  of  the  pus,  with  pellets  of  lint  before 
applying  the  caustic. 

The  thickness  of  the  eschar  produced  by  a caustic  will  depend  upon 
the  nature  of  the  substance  used,  and  the  length  of  time  it  is  kept  in 
contact  with  the  skin.  The  milder  articles,  called  catheretics,  produce 
thin,  light-colored  eschars,  which  quickly  separate  from  the  parts  be- 
low; the  stronger  ones  form  thick,  black  sloughs,  which  require  a much 
longer  period  to  become  detached  (sometimes  a month  or  even  more), 
depending  upon  the  amount  of  inflammation  produced. 

When  the  caustic  has  produced  the  effect  desired,  the  part  should 
be  thoroughly  cleansed  of  all  excess  of  the  material  employed ; this 
may  be  accomplished  with  vinegar,  if  the  caustic  is  alkaline,  or  with 
a solution  of  carbonate  of  soda,  if  it  should  be  acid. 

The  greatest  watchfulness  will  be  required  during  the  application 
of  those  caustics  capable  of  being  absorbed,  and  producing  poisonous 
effects,  such  as  the  bichloride  and  the  acid  nitrate  of  mercury  and 
arsenic,  all  of  which  have  produced  death  in  this  manner.  As  a rule, 
these  articles  should  not  be  spread  over  a large  extent  of  surface,  or  ap- 
plied upon  freshly-made  or  bleeding  wounds.  Bdrard  has  never  seen 
any  bad  results  follow  the  application  of  the  bichloride  of  mercury 
after  the  hardened  borders  of  the  sore  had  been  removed  with  the 
knife,  and  the  caustic  put  on  after  the  suppuration  was  established. 

The  fused  nitrate  of  silver  is  the  caustic  most  frequently  used  by 
surgeons;  it  produces,  when  applied  to  wounds,  a thin  white  eschar, 
which  separates  in  a day  or  two;  upon  the  skin  the  eschar  is  brownish 
or  of  a deep  violet  color. 

The  stick  of  nitrate  of  silver,  brought  to  a point,  is  employed  to 
cauterize  ulcers  of  the  cornea,  in  inflammatory  affections  of  the  con- 
junctiva and  eyelids,  in  poisoned  wounds,  to  arrest  hemorrhage  from 
leech-bites  and  small  vessels,  to  suppress  exuberant  granulations,  and 
to  abort  the  ptustules  of  variola,  &c. 

Sulphate  of  copper  is  also  a mild  caustic  or  catheretic  of  great  value 
in  the  treatment  of  inflammatory  diseases  of  the  conjunctiva,  granular 
lids,  &c.  It  is  prepared  for  use  by  selecting  a fine  large  crystal  of  the 
sulphate,  and  chipping  one  of  its  extremities  to  a smooth  point,  that 
the  conjunctiva  may  not  be  injured  by  its  roughness. 

Caustic  potassa  (potassa  fusa)  may  be  used  alone,  but  it  is  more 
commonly  mixed  with  lime,  forming  the  Vienna  plaster.  Its  action 
is  very  limited,  so  that  it  rarely  extends  to  the  subcutaneous  cellular 
tissue,  whatever  the  quantity  of  the  article  applied. 

The  eschar  is  blackish,  and  separates  in  a few  days. 

Caustic  potassa  is  sometimes  had  recourse  to  for  making  issues,  and 
opening  abscesses,  both  superficial  and  deeply  seated.  It  is  applied  in 
the  following  manner : A piece  of  adhesive  plaster  has  a perforation 
made  in  it,  and  is  then  laid  over  the  part  to  be  cauterized ; upon  this 
a fragment  of  the  caustic,  the  size  of  a pea,  is  placed,  and  a second 
piece  of  adhesive  plaster  confines  the  whole.  After  this  dressing  is 
removed,  a poultice  is  applied  until  the  eschar  comes  away,  or  the 


CAUTERIZATION. 


583 


. latter  may  be  incised  with  a knife.  This  plan  has  been  pursued  in 
opening  abscesses  of  the  liver,  where  the  object  is  to  produce  sufficient 
inflammation  to  agglutinate  the  layers  of  the  peritoneum  together 
before  issue  is  given  to  the  pus,  otherwise  a fatal  peritonitis  would  be 
likely  to  follow. 

It  may  also  be  used  to  cauterize  poisoned  wounds,  but  for  this  pur- 
pose it  is  much  inferior  to  the  liquid  caustics,  which  more  readily 
penetrate  in  every  direction  into  pockets  and  crevices  where  some 
lurking  portion  of  the  poison  might  escape  the  solid  caustic. 

The  Vienna  paste  is  prepared  with  fifty  parts  of  caustic  potassa  to 
sixty  parts  of  quicklime;  the  materials  are  to  be  thoroughly  pul- 
verized before  being  mixed,  and  then  made  into  a paste  with  a small 
quantity  of  alcohol ; the  eschar  formed  is  black,  and  comes  awayan 
eight  or  ten  days. 

This  caustic  may  be  made  in  a more  convenient  form  by  melting 
the  potassa  in  an  iron  pot,  and  then  adding  slowly  the  quicklime,  stir- 
ring the  while  with  an  iron  rod  until  the  materials  are  thoroughly 
mixed,  when  they  may  be  poured  into  cylindrical  moulds  of  sheet-lead. 

In  applying  the  Vienna  paste,  a layer  two  lines  thick,  and  of  the 
exact  size  of  the  eschar  required,  is  laid  upon  the  part;  in  five  or  six 
minutes  the  skin  will  be  cauterized  to  the  cellular  tissue,  which  is 
known  by  the  appearance  of  a gray  line  on  the  margins  of  the  paste ; 
the  caustic  should  then  be  removed  with  any  dilute  acid.  If  deeper 
cauterization  be  required,  fifteen  or  twenty  minutes  will  be  necessary. 

Arsenious  acid  forms  the  active  ingredient  of  several  cauterizing 
powders  and  pastes  which  have  enjoyed  much  reputation  for  their 
efficacy  in  destroying  cancerous  and  other  morbid  growths ; among 
these  may  be  mentioned,  as  the  best  known,  the  powders  of  Eousselot 
and  of  Dupuytren,  and  the  paste  of  Manec. 

Rousselot's  caustic  may  be  prepared  by  mixing  sixteen  parts  each  of 
the  red  sulphuret  of  mercury  and  dragon’s  blood,  with  eight  parts  of 
white  oxide  of  arsenic ; before  being  applied,  the  powder  must  be 
made  into  a paste  with  a little  gum-water. 

Manec' s paste  is  composed  of  fifteen  grains  of  arsenious  acid,  seventy- 
five  of  the  red  sulphuret  of  mercury,  and  thirty-five  of  burnt  sponge. 

A layer  of  either  of  these  preparations,  from  one  to  two  lines  thick, 
may  be  spread  upon  the  sore,  and  covered  with  lint,  over  which  a 
bandage  is  placed.  The  eschar  is  made  in  a few  days,  and  is  thrown 
off-  between  the  tenth  and  twentieth,  bringing  with  it  the  caustic  paste ; 
the  surface  beneath,  after  one  application,  will  generally  present  a 
healthy  appearance,  though  it  may  be  necessary  to  apply  it  again  and 
again  before  all  the  diseased  tissues  are  destroyed. 

Swelling  of  the  face,  and  oedema  of  the  eyelids  follow  its  applica- 
: tion  to  the  face,  but  these  subside  in  three  or  four  days  without  any 
further  accident. 

These  caustics  are  most  frequently  employed  in  the  treatment  of 
lupus  and  some  cancroid  diseases. 

The  paste  of  the  chloride  of  zinc  (Canquoin’s  caustic)  is  composed 
of  chloride  of  zinc  and  flour,  which,  absorbing  moisture  from  the 


584 


CAUTERIZATION. 


atmosphere,  becomes  converted  into  an  elastic  mass,  that  may  be 
readily  applied  to  the  surface. 

Canquoin  employed  pastes  of  three  different  strengths,  the  first  con- 
taining one  part  of  the  chloride  of  zinc  to  two  of  flour,  the  second,  one 
part  to  three ; and  the  third,  one  part  to  four. 

The  caustic  does  not  spread,  and  acts  cleanly  to  a depth  proportional 
to  the  thickness  of  the  paste  employed. 

The  acid  nitrate  of  mercury  is  also  an  active  escharotic,  but  requires 
care  in  its  management;  no  large  absorbing  surface  should  be  caute- 
rized with  this  fluid,  as  it  may  produce  excessive  ptyalism,  violent 
colics,  diarrhoea,  etc.,  and  its  use  has  in  a few  cases  resulted  in  death. 
The  part  to  which  it  is  applied  must  be  well  cleansed,  and  freed  from 
moisture ; the  caustic  may  then  be  applied  with  a brush,  or  a piece  of 
lint  mounted  upon  a wooden  stem.  It  has  been  principally  used  to 
cauterize  chancres  and  ulcerations  about  the  neck  of  the  uterus. 

Cauterizing  pastes  may  also  be  prepared  with  the  concentrated  min- 
eral acids,  with  tow,  sawdust,  asbestos,  or  saffron ; but  they  are  not 
near  so  manageable  as  Manec’s  or  Canquoin’s  caustics. 

Malgaigne  prefers  the  caustic  recommended  by  M.  R^camier  to  the 
acid  nitrate  of  mercury.  It  consists  of  a solution  of  the  chloride  of 
gold  in  nitro-chlorohydric  acid,  and  cauterizes  deeply,  while  the  eschar 
formed  by  it  separates  in  three  or  four  days.  It  gives  but  little  pain, 
and  its  action  is  purely  local. 

Dr.  Simpson  thinks  highly  of  a paste  made  of  the  sulphate  of  zinc, 
with  glycerine  or  lard  in  the  proportion  of  an  ounce  of  the  sulphate  to 
a drachm  of  glycerine,  or  two  drachms  of  lard. 

M.  Maisonneuve  reported  a plan  of  cauterization  to  the  Academy 
of  Medicine,  in  Paris,  in  1848,  differing  from  that  usually  pursued,  in 
that  the  caustic  is  made  to  act  from  the  interior  of  the  parts  to  be 
destroyed  to  their  surface. 

For  this  purpose  he  selected  the  caustic  of  Canquoin  already  men- 
tioned, from  the  fact  that  it  can  be  easily  moulded  into  any  desired 
shape,  possesses  no  toxic  effects,  and  is  a powerful  hemostatic. 

The  paste  is  rolled  into  a circular  cake,  and  cut  into  wedge-shaped 

Fig.  526.  Fig.  527.  Fig.  528. 


Maisonneuve’ s plan  of  circular  cau-  Maisonneuve’s  plan  of  parallel 
terization  by  wedge-shaped  pieces  of  cauterization  by  lancet-shaped  pie- 
caustic.  ces  of  caustic. 


Mode  of  cauterizing 
small  tumors  with  a 
spindle-shaped  piece  of 
caustic. 


MOXA. 


585 


pieces  of  an  appropriate  size  by  lines  extending  from  the  centre  to  its 
circumference ; when  dry  the  pieces  are  ready  for  use,  and  are  then 
thrust  into  the  midst  of  the  morbid  growth  through  little  incisions 
made  at  equal  distances  around  its  base,  as  seen  in  Fig.  526. 

In  other  cases,  where  the  tumor  cannot  be  circumscribed  in  this  man- 
ner, the  pieces  of  caustic  may  be  made  lancet-shaped,  and  lodged  in 
the  tumor  in  a parallel  direction,  as  seen  in  Fig.  527. 

This  process  succeeds  well  in  those  regions  where  the  morbid  tissue 
lies  deeply  among  other  parts;  as  in  the  axilla,  neck,  groin,  vagina, 
and  rectum.  Small  tumors  may  be  attacked  by  a single  spindle- 
shaped  piece  of  caustic  thrust  to  its  centre,  through  an  incision  made 
with  the  bistoury,  as  shown  in  Fig.  528. 

Mr.  Paget,  of  London,  has  employed  in  certain  cases  lancet-shaped 
pieces  of  wood  dipped  in  fused  chloride  of  zinc. 


CHAPTER  IV. 

MOXA. 

The  moxa  is  a combustible  substance,  which  is  burnt  slowly  upon 
the  skin,  usually  producing  an  eschar.  It  has  been  used  by  the  orien- 
tals in  medicine  for  centuries ; they  prepared  it  from  the  dried  leaves 
of  the  Artemisia  moxa,  a species  of  the  mugwort,  which  were  beaten 
and  formed  into  the  shape  of  small  cones.  Many  other  articles  have 
been  used  for  the  same  purpose  as  the  pith  of  the  greater 
sunflower  ( Heliantlius  aureus),  punk,  cotton,  and  paper 
rendered  more  combustible  by  soaking  it  in  a Solution  of 
the  nitrate  or  chlorate  of  potassa.  A convenient  moxa 
may  be  made  of  raw  cotton,  moderately  compressed,  and 
wrapped  with  silk  or  cotton-cloth,  so  as  to  form  a cylinder 
an  inch  long  by  one  to  two  inches  in  diameter ; this  may 
be  stuck  to  the  part,  where  the  counter-irritation  is  to  be 
established,  with  a little  gum,  or  held  in  contact  with  it 
by  a little  instrument  designed  for  the  purpose,  consisting 
of  a handle  supporting  a ring,  in  which  the  moxa  is 
secured  by  two  pins  passing  through  it,  and  the  minute 
holes  perforating  the  circumference  of  the  ring ; the 
moxa  is  then  set  on  fire  and  kept  in  a uniform  state  of 
combustion  by  a stream  of  air  driven  from  a small  blow-  „ ^ 

«y  Jrorte-moxa. 

pipe,  or,  more  simply,  from  the  mouth  alone. 

To  protect  the  surrounding  parts,  a wet  cloth  should  be  laid  over 
them ; or,  what  is  better,  a card  with  a hole  cut  in  it. 

The  combustion  should  be  allowed  to  go  on  slowly  in  order  to  pro- 
duce the  greatest  amount  of  counter-irritant  effect,  and  an  eschar  of 
sufficient  thickness,  if  the  latter  is  desired.  Where  a more  moderate 


586 


ISSUE. 


action  is  required,  a piece  of  thick  cloth,  wetted  with  water,  may  be 
interposed  between  the  skin  and  the  moxa. 

The  skin  is  at  first  reddened,  and  the  patient  experiences  a plea- 
sant sensation  of  warmth,  which,  as  the  fire  approaches  the  surface,  is 
converted  into  a decided  pain ; the  skin  crackles  as  its  moisture  is 
dissipated,  and  is  finally  converted  into  a fissured  black  eschar,  while 
the  parts  just  around  it  are  reddened  and  vesicated. 

The  eschar  separates  in  from  ten  to  fifteen  days,  leaving  a sore 
which  readily  heals. 

The  first  dressing  should  be  a simple  bit  of  adhesive  plaster,  laid 
over  the  cicatrized  surface ; and  when  pus  begins  to  ooze  from  be- 
neath its  edges  it  may  be  replaced  with  the  simple  dressing.  If  the 
resulting  inflammation  is  too  severe,  it  should  be  controlled  with 
water-dressings. 

The  moxa  should  not,  as  a rule,  be  employed  over  the  course  of 
large  vessels  or  nerves,  nor  upon  bony  prominences. 

Moxibustion  is  employed  to  produce  revulsion  in  caries  and  other 
chronic  diseases  of  the  bones,  in  obstinate  neuralgias,  and  chronic 
inflammations. 


CHAPTER  Y. 

ISSUE. 

An  issue  is  a counter-irritative,  suppurative  discharge  established 
in  the  subcutaneous  cellular  tissue.  It  is  not  so  prompt  in  its  action 
as  the  rubefacients  and  vesicants,  but  is  more  permanent  in  its  effects, 
and  more  exhaustive. 

The  issue  may  be  made  at  almost  any  point,  taking  care  always  to 
avoid  osseous  and  muscular  eminences,  and  the  courses  of  the  large 
bloodvessels  and  nerves.  It  is  usual  to  select  some  part  where  the 
issue  would  be  exempt  from  any  interference  in  consequence  of  mus- 
cular movements ; from  the  rubbing  of  the  clothes  against  it,  &c. ; and 
at  the  same  time  permit  the  convenient  application  of  the  necessary 
dressings. 

In  local  diseases  it  will  generally  be  desirable  to  place  the  issue 
over  the  suffering  organ,  or  as  near  to  it  as  possible. 

The  point  of  selection,  in  affections  of  the  head,  is  the  back  of  the 
neck.  Velpeau  prefers  the  triangular  space  bounded  above  by  the 
occiput,  at  the  sides  by  the  splenic  muscles,  and  having  its  apex  at 
the  spinous  process  of  the  axis ; his  reason  is,  that  in  this  spot  there 
is  a thick  bed  of  cellular  tissue  and  muscle  in  direct  vascular  connec- 
tion with  the  internal  parts,  and  in  proximity  with  large  and  import- 
ant nerves.  Others  recommend  that  jit  be  placed  lower  down,  so 
that  it  may  be  concealed  by  the  dress.  In  the  arm,  the  space  be- 


ISSUE. 


587 


tween  the  deltoid  and  bleeps,  near  the  insertion  of  the  former  muscle, 
will  be  found  most  eligible. 

An  issue  for  the  lower  extremity  is  generally  established  at  the 
depression  upon  the  inner  side  of  the  thigh,  about  two  or  three  inches 
above  the  inner  condyle,  just  over  the  vastus  internus;  though  in 
this  situation  the  dressings  are  not  so  easily  maintained,  both  from 
the  conicity  of  the  thigh  and  the  disturbing  influences  of  locomotion. 
The  points  above  mentioned  are  the  most  desirable  for  the  establish- 
ment of  a permanent  issue.  For  temporary  counter-irritation,  while 
the  patient  is  confined  to  bed,  any  part  above  the  suffering  organ, 
with  the  exception  we  have  made  above,  may  be  chosen — in  dis- 
eases of  the  lungs,  the  depressions  beneath  the  clavicles ; in  those  of 
the  abdomen,  over  the  liver,  duodenum  and  iliac  fossa,  according  to 
the  situation  of  the  organ.  In  affections  of  the  spine,  any  portion  of 
the  vertebral  grooves  will  answer  for  the  seat  of  the  issue — alongside 
of  any  particular  vertebra  that  may  be  diseased. 

Issues  are  made  in  several  ways ; the  first  and  most  valuable  is 
with  the  actual  cautery.  The  iron  should  be  heated  to  whiteness,  and 
applied  quickly  to  the  part,  and  as  quickly  removed  before  it  has 
time  to  cool.  The  eschar  formed  is  black,  and  generally  separates  in 
five  or  six  days.  Water-dressings  should  be  employed  until  this 
occurs,  and  the  surface  kept  discharging  by  the  application  of  some 
stimulating  ointment  or  foreign  body;  or,  what  is  better,  by  passing 
the  heated  iron  slightly  over  the  surface  as  occasion  requires. 

When  the  iron  is  white  hot,  there  is  no  great  pain  produced,  for  the 
obvious  reason  that  the  nerves  of  the  part  are  instantly  deprived  of 
their  vitality. 

The  potential  cautery  is  also  employed  for  the  same  purpose.  In 
using  the  potassa  fusa  it  should  be  remembered  that  the  eschar  will 
he  twice  as  large  as  the  fragment  of  caustic,  from  its  great  tendency 
to  spread;  its  mode  of  application  has  already  been  described  at  page 
582.  At  the  end  of  five  or  six  hours,  or  -when  the  pain  ceases,  the 
dressings  should  be  removed  and  the  part  examined ; in  the  centre  of 
a circle  of  inflammation  will  be  found  the  black  and  dead  integument, 
forming  an  eschar,  which  it  is  now  the  object  to  get  rid  of;  a poultice 
may  be  applied  repeatedly,  which  will  bring  away  more  or  less  of  the 
slough  at  every  dressing ; in  this  manner  in  from  ten  to  twenty  days 
it  will  be  completely  removed. 

Irritating  ointment  or  peas  are  then  applied  to  keep  the  sore 
discharging. 

Some  have  recommended  the  eschar  to  be  cut  across,  a pea  put  in 
the  incision  and  confined  with  a bandage : as  the  issue  progresses  the 
eschar  softens,  turns  gray,  and  finally  drops  off,  leaving  a clean  granu- 
lating surface  beneath,  which  must  be  kept  discharging  by  peas, 
glass  beads,  or  other  irritants,  to  which  a thread  may  be  attached  to 
facilitate  their  removal  when  it  becomes  necessary. 

The  Vienna  paste  is  preferable  to  the  potassa  fusa  in  making  an 
issue,  inasmuch  as  it  does  not  spread  upon  the  surrounding  tissues,  in 
consequence  of  the  lime  it  contains  restraining  the  fluidity  of  the 
caustic  potassa,  while  at  the  same  time  it  renders  this  more  active  by 


588 


ISSUE. 


seizing  any  carbonic  acid  that  may  be  present  in  it.  The  eschar 
formed  is  of  a pale  drab  color,  and  separates  in  seven  or  eight  days. 

The  caustic  is  applied  in  the  same  manner  as  the  potassa  fusa,  and 
permitted  to  remain  in  contact  with  the  skin  ten  or  fifteen  minutes, 
when  it  is  removed  by  washing  the  part  in  some  dilute  acid ; a poultice 
is  then  applied. 

Blisters  have  been  used  to  make  an  issue,  but  the  process  is  ineffi- 
cient and  painful ; the  blister  simply  destroys  the  cuticle,  and  the  peas 
have  to  be  bound  on  so  that  they  may  penetrate  the  cutis  by  ulcera- 
tion; in  this  manner  the  discharge  of  pus  will,  of  course,  be  delayed, 
and  its  quantity  be  small  until  this  result  is  obtained. 

Dr.  Golding  Bird  has  recommended  the  following  plan  to  procure 
a clean,  healthy  granulating  surface  with  a free  discharge  of  pus: 
Apply  two  small  blisters  within  a few  inches  of  each  other,  and  after 
the  vesicles  are  formed  discharge  the  serum ; over  the  blister  intended 
for  the  issue  place  a zinc  plate,  and  upon  the  other  one  a silver  plate, 
then  connect  the  two  together  with  a copper  wire.  In  forty-eight 
hours  a decided  eschar  will  be  formed  under  the  zinc  plate,  and  sup- 
puration will  be  established  in  four  or  five  days,  when  tbe  apparatus 
must  be  removed  and  a poultice  applied;  the  skin  beneath  the  silver 
plate  will  be  found  entirely  healed. 

The  explanation  of  the  action  of  the  apparatus  is  that  the  galvanic 
current  decomposes  the  chloride  of  sodium  of  the  serum,  evolving 
chlorine  at  the  positive,  or  zinc  pole,  which,  seizing  hold  of  that 
metal,  forms  the  chloride  of  zinc,  the  well-known  escharotic. 

The  quickest  and  least  painful  manner  of  forming  an  issue  is  with 
the  knife ; but  it  is  inferior  to  the  other  plans  in  its  immediate  revul- 
sive action,  as  the  irritation  of  a clean  cut  bears  no  comparison  with 
the  slow  destructive  effects  of  the  caustics  or  the  violent  impression 
of  the  actual  cautery. 

This  method  is  better  adapted  to  the  scalp  than  to  any  other  region, 
and  has  been  pursued  in  certain  affections  of  the  meningeal  membranes. 
The  incision  should  be  from  a half  to  an  inch  in  length,  proportional 
to  the  size  of  the  issue ; and  rather  than  make  a long  incision,  a 
crucial  one  should  be  preferred  through  the  skin  and  cellular  tissue ; 
in  this  incision  place  some  foreign  body,  as  a garden  pea,  a small 
piece  of  gentian  or  orrisroot,  a grain  of  corn,  a small  pebble,  or  a 
glass  bead,  which  will  produce  the  suppurative  action  in  three  or  four 
days.  Should  this  be  delayed,  the  foreign  body  may  be  spread  with 
some  stimulating  ointment,  mezereou,  for  instance.  After  the  suppura- 
tion is  once  established,  a simple  dressing  once  a day  will  generally 
suffice  to  insure  cleanliness.  If  the  granulations  become  fungous, 
they  should  be  repressed  with  the  nitrate  of  silver ; severe  inflamma- 
tion must  be  met  with  water-dressings,  poultices,  &c. 

An  issue  may  be  readily  healed  by  withdrawing  the  irritating  body 
from  it,  and  substituting  a simple  dressing. 


SETON. 


589 


CHAPTER  VI. 

SETON. 

The  seton,  from  seta,  a “bristle,”  is  made  by  passing  a strip  of  some 
material  beneath  a narrow  tongue  of  the  skin  and  cellular  tissue,  to 
establish  a secretion  of  pus.  The  name  is  applied  both  to  the  wound 
made  and  to  the  material  put  into  it. 

Occasionally  the  seton  is  used  with  other  views  than  as  an  exutory, 
as  when  a thread  or  cord  is  introduced  into  the  tunica  vaginalis,  or 
between  the  ends  of  a broken  bone.  Here  the  object  is,  in  the  first 
case,  to  excite  the  adhesive  inflammation,  and  in  the  second,  to  cause 
an  effusion  of  reparative  material.  It  has  also  been  placed  in  cavities, 
to  facilitate  the  escape  of  a foreign  body,  as  in  old  gunshot  wounds 
where  the  projectile  has  not  yet  escaped;  but  for  this  purpose  it  is 
now  obsolete. 

Again,  where  there  is  a constriction  of  some  duct  of  the  secreting 
glands,  the  seton  is  had  recourse  to,  to  dilate  it ; as  in  fistula  lachry- 
malis,  and  in  Stenon’s  duct  in  salivary  fistula. 

As  an  exutory,  setons  are  now  generally  applied  to  the  neck  about 
the  height  of  the  fourth  or  fifth  cervical  vertebra,  and  to  the  inner 
sides  of  the  extremities;  they  have  also  been  used  upon  the  chest  and 
abdomen,  and,  in  obstinate  disease  of  the  uterus  and  bladder,  over  the 
pubis. 

In  very  irritable  subjects  this  mode  of  counter-irritation  is  extremely 
painful,  and  will  often  have  to  be  abandoned  for  some  other  method, 
more  especially  if  inflammation  and  suppuration  of  the  cellular  tissue 
to  a considerable  extent  follow,  as  they  sometimes  do ; in  these  cases 
the  little  tongue  of  skin  usually  sloughs,  leaving  an  open  wound. 

The  operation  is  simple,  and  may  be  performed  with  the  seton- 
needle,  or  with  an  eye-probe  and  bistoury.  The  seton-needle,  as  seen 


Fig.  530. 


in  Fig.  580,  is  a flat,  lance-shaped  instrument,  four  or  five  inches  long, 
by  six  lines  broad,  with  a large  eye  at  its  heel,  to  carry  the  thread  or 


590 


SETON. 


tape.  It  is  -used  by  raising  a fold  of  the  integuments  between  the 
fingers,  and  thrusting  the  needle  through  its  base,  when  the  point  of 
the  needle  is  seized  and  the  threads  drawn  into  their  place. 

The  second  method,  with  the  bistoury  and  probe  (Fig.  531),  is  better, 
as  these  instruments  are  always  at  hand,  and,  in  drawing  the  seton  into 
the  wound,  the  fingers  will  not  slip  from  the  probe,  as  they  do  from  the 
needle  covered  with  blood  and  resisted  by  the  elasticity  of  the  tissues. 

A fold  of  skin  is  raised  with  the  thumb  and  three  fingers  of  the  left 
hand ; the  bistoury,  held  in  the  right,  with  the  edge  downwards,  is 
passed  through  its  base,  giving  the  point  of  the  knife  a little  inclina- 
tion downwards,  so  that  one  of  the  parallel  incisions  may  be  a little 
longer  than  the  other,  in  order  to  facilitate  the  escape  of  pus;  the 
probe,  armed  with  the  seton,  is  now  passed  beneath  the  skin  upon  the 


Fig.  531. 


Mode  of  introducing  a seton. 


back  of  the  blade  of  the  bistoury,  when  the  latter  is  to  be  withdrawn, 
while  the  seton  is  pulled  into  the  position  it  is  destined  to  occupv. 
A little  blood  escapes  from  the  wound  at  first,  but  soon  ceases,  and  in 
three  or  four  days  suppuration  is  established. 

The  material  of  which  a seton  is  made  is  a skein  of  cotton,  a narrow 
piece  of  cotton  cloth,  or,  what  is  better  yet,  a thin  slip  of  India-rubber. 
This  is  to  be  drawn  beneath  the  skin  a little  way  at  each  dressing; 
and  when  it  is  exhausted,  before  the  last  remnant  is  removed,  a new 
slip  should  be  loosely  tacked  to  its  end,  to  be  pulled  into  the  wound 
in  its  turn.  If  a strip  of  India-rubber  is  employed,  it  does  not  need 
renewing,  but  may  be  simply  sponged  clean. 

The  long  end  of  the  seton  should  be  on  the  side  of  the  shortest 
incision,  so  that  it  may  not  be  soiled  by  the  pus. 

As  to  the  dressing,  a poultice  may  be  applied  until  the  suppurative 
action  is  established,  and  then  a simple  dressing,  or  a perforated  com- 
press smeared  with  cerate,  may  be  laid  on  the  wound  and  covered 
with  a little  charpie,  the  whole  being  secured  by  the  circular  bandage 
of  the  neck.  This  dressing  need  not  be  disturbed  for  three  or  four 
days,  and  after  the  wound  begins  to  suppurate  it  should  be  dressed 
every  day;  if  the  discharge  is  very  abundant,  twice  daily,  the  soiled 
part  of  the  seton  being  removed  with  the  scissors. 

Should  the  suppurative  action  be  tardy,  a little  ointment  of  basilicon 
or  cantharides  may  be  put  on  the  seton. 

This  mode  of  making  counter-irritation  is  far  inferior  to  that  by 
the  issue,  being  less  cleanly  and  efficient. 


ACUPUNCTURE  AND  ELECTRO-PUNCTURE. 


591 


CHAPTER  VII. 

ACUPUNCTURE  AND  ELECTRO-PUNCTURE. 

II.  Acupuncture  consists  in  the  introduction  of  metallic  needles 
into  the  tissues  of  the  body.  It  is  an  extremely  simple  operation,  the 
needles  passing  between  the  fibres  without  dividing  them  or  shedding 
blood. 

The  method  was  introduced  into  Europe  by  the  Dutch  surgeon, 
Then-Ryne,  who  had  resided  on  the  island  of  Desima,  at  Nangasaki,  in 
Japan,  and  there  learned  the  plan.  It  is  of  the  highest  antiquity,  accord- 
ing to  the  Oriental  physicians,  and  I have  seen  it  generally  practised  by 
the  native  surgeons  both  in  China  and  Japan.  The  needles  used  may 
he  made  of  gold,  silver,  platinum,  or  steel ; they  should  be  slender, 

■ sharp,  and  well  polished,  in  order  to  penetrate  the  tissues  without  dif- 
ficulty. A small  steel  handle,  with  a ring  at  one 
iend  and  a socket  at  the  other,  to  receive  the  needles, 
completes  the  instrument  either  for  acupuncture  or 
electro-puncture.  In  employing  the  needle,  it  may 
he  seized  in  the  hand,  and  plunged,  at  one  stab,  to 
the  required  depth  into  the  painful  part,  or  driven 
in  by  a quick,  smart  blow  with  a ruler.  I prefer, 
however,  to  rotate  the  needle  between  the  thumb 
and  index  finger,  making  gentle  pressure  all  the 
time  until  the  point  of  the  needle  is  put  in  the 
position  required. 

The  operation  has  been  practised  upon  almost 
every  part  of  the  body,  but  it  will  be  prudent  to 
iavoid  thrusting  the  needle  into  the  splanchnic  cavi- 
ties and  large  bloodvessels;  with  these  exceptions, 
the  instrument  may  be  shoved  boldly  into  any  part 
of  the  body  to  a depth  of  one,  two,  or  three  inches, 
as  circumstances  may  direct. 

The  number  of  needles  that  will  be  required  in 
any  case  will  vary  from  three  or  four  to  twelve ; I 
introduced  twenty  in  an  obstinate  case  of  sciatica  with  advantage.  They 
may  be  permitted  to  remain  in  for  a few  minutes — or,  as  is  generally 
done,  two  or  three  hours;  there  will  be  no  objection  to  extending  the 
time  to  two  or  three  days. 

To  remove  the  needle,  press  the  skin  at  the  point  of  puncture  with 
the  tips  of  the  fore  and  middle  fingers  of  the  left  hand,  and  draw  the 
handle  towards  you  with  the  right. 

Usually  a little  blush  of  redness  will  surround  the  puncture,  and 
perhaps  a slight  numbness  will  be  present ; though  in  certain  cases 
patients  have  been  known  to  suffer  extreme  pain  during  the  opera- 
tion and  after  the  needle  has  been  removed.  In  a few  instances, 


Figa.  532,533,  534. 


Acupuncture  needles. 


692 


PUNCTURING. 


where  the  needles  have  not  been  properly  tempered,  they  have  been 
broken  by  the  strong  muscular  contractions  excited  by  them. 

Acupuncture  has  been  recommended  in  the  treatment  of  neuralgia, 
sciatica,  angina  pectoris,  paralysis,  chronic  rheumatism,  and  chronic 
gout.  Recently  it  has  been  used  in  aneurism,  anasarca,  hydrocele,  and 
varicocele.  I know  of  two  cases  of  hydrocele  radically  cured  by  the 
persevering  use  of  the  needles.  Carrero  has  employed  it  also  in  cases 
of  asphyxia  from  drowning,  and  other  causes,  by  thrusting  the  needles 
into  the  heart  and  diaphragm.  # 

2.  Electro-puncture  is  performed  after  the  needles  have  been  intro- 
duced as  above  directed,  by  attaching  to  the  rings  of  the  steel  handles 
the  poles  of  a galvanic  battery,  and  sending  a current  of  electricity 
through  the  tissues  intervening  between  the  needles.  If  it  is  desira- 
ble to  communicate  a shock,  the  Leyden  jar,  charged  with  electricity, 
may  be  used.  During  the  passage  of  the  current  the  patient  feels 
more  or  less  pain,  and  an  unpleasant  contraction  of  the  muscles,  which 
cease  with  the  interruption  of  the  current.  Over  the  electrized  part 
little  blisters  and  boils  sometimes  form. 

Electro-puncture  has  been  used  in  the  same  kind  of  cases  as  acu- 
puncture. 


CHAPTER  VIII. 

PUNCTURING. 

Puncturing  is  the  operation  of  thrusting  an  instrument  either 
sharp  at  its  point  only,  or  also  cutting  upon  its  edges,  into  the  tissues 
or  cavities,  natural  or  morbid,  of  the  body. 

The  simplest  form  of  a puncture  consists  in  making  little  wounds 
into  the  skin  or  mucous  membrane  with  a needle,  to  evacuate  infil- 
trated fluids  beneath  them.  This  operation  may  be  performed  upon 
any  part  of  the  body,  as  the  scrotum  and  legs  in  dropsical  effusions; 
the  instrument  required  is  a needle,  or  a very  slender-pointed  bis- 
toury, which  should  be  thrust  perpendicularly  through  the  skin,  and 
withdrawn  in  the  same  direction  without  enlarging  the  wound;  the  fibres 
are  simply  separated,  and  no  loss  of  substance  or  cicatrix  follows. 

Great  care  should  be  taken  in  puncturing  the  skin  in  oedematous 
leg,  as  it  becomes  very  thin  by  the  pressure  of  the  effused  fluids,  and 
impaired  in  its  nutritive  activity.  Instrumental  interference  has  some- 
times caused  an  erysipelatous  inflammation,  resulting  in  gangrene. 

Scarification  differs  from  puncturing  in  that  the  point  of  the  lancet 
or  bistoury  penetrates  the  tissues  more  deeply,  and  divides  the  fibres 
of  the  parts;  in  fact  it  consists  in  making  little  incisions. 

The  operation  can  be  performed  either  with  the  lancet,  scalpel,  or 
scarificator. 

It  is  employed  in  phlegmonous  erysipelas  to  favor  the  escape  of 
pus,  in  chemosis,  in  sanguineous  congestions  of  the  tongue  and  tonsils, 
and  in  oedema  of  the  glottis. 


PUNCTURING. 


593 


Manner  of  holding  the  bistoury  in  opening  abscesses. 


Fig.  536. 


For  the  purpose  of  evacuating  the  fluid  accumulated  in  morbid 
or  the  natural  cavities,  the  lancet,  bistoury,  or  trocar  is  used. 

In  opening  abscesses,  the 

bistoury  is,  perhaps,  the  Fig.  535. 

best  instrument ; it  should 
be  held  in  the  manner 
shown  in  Fig.  535,  when 
the  hand  is  steadied  with 
the  little  finger,  while  the 
instrument  is  pushed  for- 
ward by  the  movements  of 
' the  thumb,  index,  and  mid- 
dle fingers.  The  puncture 
should  be  made  generally 
at  the  thinnest  part  of  the 
swelling,  and  in  a line  pa- 
rallel with  its  long  axis, 
should  no  special  reason  require  it  to  be  done  otherwise. 

Mr.  Fergusson  deems  the  attitude  seen  in  Fig.  536  best  suited  to 
cases  where  pus  is  deep-seated,  and 
when,  probably,  the  surgeon  has 
misgivings  as  to  its  presence  at  all. 

The  forefinger  of  the  left  hand  is 
placed  over  the  abscess  with  gentle 
pressure;  the  back  of  the  knife  rests 
against  the  side  of  the  finger  while 
the  tissues  are  divided  to  the  desired 
extent. 

Should  “Syme’s  abscess  lancet” 
be  employed,  the  best  position  for 
holding  it  to  prevent  its  point  sud- 
denly plunging  into  the  abscess  is 
that  seen  in  Fig.  537,  in  which  the 
hand  is  steadied  and  supported  with 
the  little  finger. 

In  puncturing  the  chest  and  abdo- 
men, an  instrument  called  the  trocar 
(Fig.  538)  is  used  ; it  is  a cylindrical 
metallic  stem  fitted  to  a large  bulb- 
ous handle,  and  terminating  in  a 
sharp  point  with  three  cutting  edges ; 
fitting  over  this  stem  there  is  a mova- 
ble tube,  resting  against  the  handle 
by  its  funnel-shaped  expansion,  and 

reaching  within  a quarter  of  an  inch  of  the  point  of  the  stem,  which 
it  should  clasp  closely,  that  there  may  be  no  jutting  shoulder  to  im- 
pede its  progress  through  the  tissues. 

In  using  this  instrument,  it  is  held  in  the  palm  of  the  right  hand 
by  the  last  three  fingers  and  the  thumb  resting  against  the  junction 
of  the  stem  with  the  handle,  while  the  index  finger  is  extended  along 
38 


Manner  of  holding  the  bistoury  in  opening 
deep-seated  abscesses. 


594 


VACCINATION. 


the  canula  to  graduate  the  depth  to  which  the  point  is  to  he  plunged; 
it  is  then  to  he  thrust  into  the  cavity  quickly  and  the  trocar  removed, 

Fig.  537. 


Mode  of  holding  “ Syme’s  abscess  lancet.” 

leaving  the  canula  in  the  wound.  When  the  cavity  is  large,  as  the 
fluid  escapes  its  walls  collapse,  and  the  canula  will  he  displaced  if  the 
operator  does  not  support  it  with  his  fingers ; the  position  of  the 
point  of  the  canula  may  also  he  changed  occasionally  to  facilitate  the 
escape  of  the  fluid. 


Fig.  538. 


The  trocar. 


Valvular  puncture  differs  from  the  foregoing  only  in  the  skin  being 
shifted  a little  to  one  side  before  the  puncture  is  made,  so  that  after 
the  fluid  escapes,  and  the  instrument  is  withdrawn,  the  internal  and 
external  orifices  do  not  correspond  when  the  parts  again  resume  their 
normal  relation. 


CHAPTER  IX. 


VACCINATION. 


Vaccination  is  a process  which  consists  in  inserting  the  vaccine 
virus  beneath  the  cuticle,  so  that  it  may  come  in  contact  with  the 
absorbents. 

This  little  operation  can  be  performed  at  any  point  of  the  sur- 
face, though  the  place  of  electiun  should  always  be  the  arm.  and  in 
infants  the  arm  farthest  from  the  nurse  in  the  position  they  are  usually 
carried. 


VACCINATION. 


595 


The  virus  is  effective  in  persons  of  all  ages,  though  it  is  always 
prudent  to  perform  the  operation,  when  there  is  any  choice  left,  at 
the  age  of  three  or  four  months. 

Some  persons  bring  the  virus  in  contact  with  the  absorbents  by 
simply  scratching  the  cuticle  from  the  cutis  with  the  point  of  a lancet ; 
some  make  three  or  four  little  incisions  into  the  skin  at  right  angles 
to  each  other ; others  again  form  little  pockets  by  pushing  the  point 
of  the  lancet  obliquely  between  the  epidermis  and  true  skin  a distance 
of  the  one-sixteenth  of  an  inch. 

Some  physicians  prefer  an  instrument  specially  constructed  for 
vaccination;  it  resembles  the  ordinary  lancet  somewhat,  though 
smaller,  and  has  a slight  groove  upon  one  side  of  the  point  of  the 
blade  to  receive  the  virus  which  is  obtained  from  the  vaccine  vesicle 
between  the  sixth  and  tenth  day  of  its  appearance,  when  it  should  be 
limpid ; or,  as  is  more  commonly  done,  a small  piece  of  the  scab  is 
powdered  and  mixed  with  water. 

When  the  operation  is  terminated,  the  arm  is  left  exposed  to  the 
air  for  some  time,  until  the  blood  dries  upon  the  surface  to  protect 
the  vaccine  matter  in  the  punctures;  a loose  circular  bandage  of  soft 
linen  may  then  be  applied  to  prevent  the  chafing  of  the  arm. 

About  the  end  of  the  third  day,  after  a successful  vaccination,  the 
skin  a little  way  around  the  puncture  becomes  hard  and  a little  red ; 
on  the  fifth  or  sixth  day  the  areola  increases  in  size,  and  an  eff  usion 
I'  takes  place  beneath  the  cuticle,  forming  a vesicle  of  a roundish  form 
and  of  a silvery  or  pearly  color;  the  vesicle  is  depressed  at  its  centre, 
or  umbilicated ; and  continues  to  increase  in  size  to  the  eighth  day, 
when  the  fluid  is  limpid  and  transparent  and  contained  in  a number 
of  little  cells;  on  the  ninth  day  the  vesicle  becomes  darker  at  its 
centre,  which  has  ceased  to  present  the  umbilicated  appearance,  and 
j becomes  flattened  ; the  areola  surrounding  it  has  gradually  increased 
in  size,  become  of  a vivid  red  color,  and  occasionally  presenting  a 
number  of  transparent  vesicles.  On  the  tenth  day,  the  swelling  and 
heat  in  the  part  have  considerably  increased,  restraining  the  free  motion 
of  the  arm  ; the  glands  in  the  axilla  are  swollen  and  tender.  At  this 
time  the  patient  experiences  some  little  febrile  excitement,  and  occa- 
sionally there  is  an  erythematous  blush  over  other  parts  of  the  body. 
On  the  eleventh  day,  the  fluid  in  the  vesicle  becomes  purulent  and  the 
areola  commences  to  fade,  and  the  general  symptoms,  if  the}r  have  been 
present,  diminish  in  intensity ; or  disappear  if  they  have  been  slight. 
The  desiccation  of  the  vesicle  proceeds  from  the  centre  to  the  circum- 
ference until  it  is  converted  into  a brownish  circular  scab  which  deepens 
in  color  to  a brownish  black  in  a few  days,  and  diminishes  in  size ; the- 
inflamed  areola  has  decreased  apace  with  the  desiccation  of  the  vesicle 
until  the  twentieth  day,  when  the  crust  falls  off)  leaving  a depressed 
cicatrix  of  a circular  contour  with  little  pits  upon  its  surface.  As  it, 
is  not  always  convenient  or  even  possible  to  transfer  the  vaccine  virus 
from  one  arm  to  another  (though  it  is  evidently  the  most  efficient  way), 
it  is  important  that  proper  care  should  be  taken  to  preserve  the  “scabs;”’ 
and  in  collecting  these,  that  the  subjects  from  whom  they  are  obtained 


596 


INCISIONS. 


shall  present  palpable  evidence  of  exemption  from  any  scrofulous  or 
venereal  taint,  chronic  skin  diseases,  and  general  debility. 

The  crusts  may  be  preserved  for  a long  time  by  wrapping  them 
in  alternating  layers  of  yellow  or  white  wax  and  tin-foil.  I vacci- 
nated a patient  successfully  with  matter  thus  protected  nearly  two 
years  old. 

To  collect  the  lymph  from  a vesicle,  the  best  plan,  according  to 
MM.  Bretonneau  and  Fiard,  is  to  use  capillary  glass  tubes,  which,  after 
the  fluid  has  been  drawn  into  them,  are  to  be  hermetically  sealed  by- 
holding  their  extremities  for  a moment  in  the  flame  of  a spirit  lamp. 

Another  plan  consists  in  receiving  the  virus  from  the  vesicle  upon 
a glass  plate,  to  which  it  will  adhere;  another  glass  plate  is  now  laid 
over  the  first,  and  their  edges  joined  together  with  wax  or  by  pasting 
paper  around  them. 

Jenner  soaked  up  the  fluid  with  threads;  the  vaccine  virus  is  in 
this  method  always  exposed  to  the  air,  and  is  soon  destroyed. 

The  lymph  may  also  be  received  upon  ivory,  pearl,  or  horn  slips 
shaped  like  the  blade  of  a lancet,  and  sharp  enough  to  enable  the 
surgeon  to  thrust  their  points  beneath  the  skin. 

To  preserve  the  matter  for  a few  hours  the  point  of  a lancet  will 
answer  ; but  after  this  time  the  metal  quickly  oxidizes  and  destroys 
the  virus. 

Should  an  unusual  amount  of  inflammatory  action  take  place  around 
the  vesicle,  a soft  linen  rag  wrung  out  of  hot  water  may  be  laid  on 
the  parts ; or  a solution  of  the  subacetate  of  lead,  taking  care  not  to 
rub  the  crust  off  the  arm. 

Vaccinia  having  run  the  ordinary  course  described  above,  the  patient 
is  generally  preserved  the  balance  of  his  life  from  smallpox — I say, 
generally , for  instances  are  recorded  where  smallpox  has  attacked 
patients  after  successful  vaccination. 


CHAPTER-  X. 


INCISIONS. 

Incisions  are  solutions  of  continuity  of  the  soft  tissues  made  with 
cutting  instruments.  They  are  so  constantly  employed  in  various 
manners  by  the  surgeon  in  the  routine  of  practice  as  to  constitute  a 
large  portion  of  operative  surgery ; hardly  a surgical  procedure  can 
be  accomplished  without  involving  to  a greater  or  less  extent  the 
division  of  the  tissues.  They  often  constitute  in  themselves  little 
operations,  as  the  opening  of  abscesses,  scarifications,  punctures,  kc. 
The  larger  operations,  as  amputations,  ablations  of  tumors,  &c.,  are 
nothing  more  than  simple  incisions  variously  modified  to  suit  the 
exigencies  of  particular  cases. 


INCISIONS. 


597 


Incisions  are  practised  with,  a variety  of  instruments,  but  those 
principally  used  are  scalpels,  bistouries,  and  the  scissors. 

Certain  rules  have  been  laid  down  by  some  distinguished  surgeons 
to  govern  the  manner  of  holding  the  knife ; and  although  most  per- 
sons will  hold  the  instrument  as  best  suits  their  convenience  and  the 
attainment  of  the  object  they  have  in  view,  yet  it  will  be  well  for  the 
young  surgeon  to  learn  early  those  positions  which  have  been  found 
by  experience  to  be  the  most  convenient  and  graceful  in  making  the 
various  incisions  required  in  operating. 


Fig.  539. 


Scalpel  held  as  a pen. 


In  Fig.  539  the  scalpel  is  held  as  a pen,  with  its  edge  downwards ; 
the  index-finger  and  thumb  supporting  it  at  the  junction  of  the  blade 
with  the  handle;  the  middle  finger  is  a little  in  advance  of  the  index, 
upon  the  side  of  the  blade ; the  ring  and  little  fingers  are  free,  and, 
resting  upon  the  skin,  serve  to  support  the  hand.  This  position  is 
convenient  in  making  punctures  and  short  incisions ; in  those  of  greater 
length,  the  hand  may  be  drawn  along  the  surface,  still  steadied  by  the 
ring  and  little  fingers,  or  the  latter  may  be  raised  from  the  skin  so  as 
to  give  it  the  greatest  latitude  of  motion.  The  pressure  upon  the 
knife  must  be  proportioned  to  the  depth  it  is  necessary  to  carry  the 
incision,  the  resistance  of  the  tissues,  and  the  proximity  of  important 
parts. 

This  position  may  sometimes  be  advantageously  modified  by  turn- 
ing the  edge  of  the  blade  upwards,  as  in  cutting  upon  a director  from 
within  outwards,  opening  abscesses,  &c.;  or,  again,  by  drawing  the 
blade  beneath  the  palm  of  the  hand,  with  its  edge  either  turned  up  or 
down,  according  as  the  operator  desires  to  cut  towards  or  from  himself. 

In  Fig.  540  is  shown  a method  in  which  the  thumb  is  placed  upon 
the  articulation  of  the  blade  with  the  handle,  and  the  fingers  upon  the 


Fig.  540. 


opposite  side;  it  permits  the  freest  movements  of  the  knife,  and  is 
adapted  to  rapid  and  extensive  incisions.  The  cutting  edges  can  be 
directed,  according  to  circumstances,  upwards  and  downwards,  or  to 
either  side. 


598 


INCISIONS. 


A very  elegant  position,  in  which  the  hand  has  the  most  perfect 
control  over  the  knife,  is  seen  in  Fig.  541.  The  handle  is  held  in  the 

palm  of  the  hand  by  the  ring 
Flg-  54L  and  little  fingers,  the  thumb 

and  middle  finger  being  placed 
near  the  articulation,  while  the 
index  is  extended  along  the 
back  of  the  blade. 

There  a're  several  modes, 
also,  of  making  incisions  either 
from  within  outwards,  or  the 
reverse ; upon  a director,  or 
without  one;  and  in  certain 
cases,  where  the  part  to  be 
divided  is  some  distance  below 
the  surface,  and  cannot  be  seen, 
the  point  of  the  finger  may  be 
used  as  a director  upon  which 
the  point  of  the  knife  may  be 

Bistoury  held  as  a carving-knife.  guided,  and  at  the  Same  time 

prevented  from  damaging  the 
surrounding  organs;  this  method  is  sometimes  employed  in  dividing 
constricting  bridles,  as  in  relieving  strangulated  hernia.  (Fig.  542. ) 

Fig.  542. 


Manner  of  using  bistoury  with  the  finger  as  a director. 

The  direction  of  incisions  will  vary  in  each  case,  according  to  the 
objects  the  surgeon  desires  to  obtain,  and  it  may,  therefore,  run  from 
right  to  left,  from  left  to  right,  towards  the  operator,  or  in  the  contrary 
direction.  As  a general  rule,  it  will  be  desirable,  if  possible,  to  make 
incisions  in  the  same  direction  as  the  muscular  fibres,  large  bloodves- 
sels, and  nerves;  so  that  in  the  extremities  they  would  be  longitudinal, 
oblique  over  the  pectoral  and  abdominal  muscles,  and  parallel  with 
the  natural  folds  in  the  palms  of  the  hands,  groins,  and  soles  of  the 
feet,  and  with  the  branches  of  the  facial  nerve  upon  the  face. 

In  making  an  incision  with  the  knife,  in  order  to  avoid  the  partial 
division  of  the  skin  at  the  extremities  of  the  incision,  and  thereby 
forming  what  are  technically  called  “tails,”  the  instrument  should  be 
introduced  perpendicular  to  the  surface,  then  brought  down  to  a less 
angle  with  it,  and  drawn  along  to  the  desired  extent;  when  the  handle 
is  to  be  again  elevated,  and  the  blade  withdrawn  perpendicularly. 


INCISIONS. 


599 


That  the  incision  may  be  neat,  it  will  be  necessary  to  stretch,  or  at 
least  to  support,  the  integuments  while  the  scalpel  is  cutting  through 
the  tissues.  This  may  be  done  with  the  outer  border  of  the  left  hand 
and  thumb  placed  in  a parallel  position  upon  each  side  of  the  incision, 
and  exercising  gentle  traction  in  opposite  directions ; or  the  part  may  be 
grasped  in  the  left  hand  at  a point  opposite  the  incision,  and  with  the 
fingers  and  thumb  moderately  tighten  the  skin ; this  plan  is  adapted 
to  those  portions  of  the  body,  such  as  the  testicles,  and  the  smaller  sec- 
tions of  the  limbs,  that  the  surgeon  can  encircle  with  his  hand.  The 
same  purpose  may  be  also  accomplished  by  making  the  incision  be- 
tween the  left  index  and  middle  fingers  laid  parallel  upon  the  surface. 

Simple  incisions  are  those  made  with  one  stroke  of  the  scalpel,  and 
are  those  most  frequently  used;  they  may  either  be  straight  or  curved, 
as  seen  in  Figs.  543  and  544;  both  of 
them  are  made  in  the  manner  already  de- 
scribed; in  the  curved  incision  the  con- 
vexity may  be  directed  towards  any  point 
that  may  be  deemed  best  to  secure  the 
object  in  view. 

Compound  incisions  are  those  formed  by  the  meeting  of  two  or  more 
simple  ones,  and  receive  the  names  of  the  letters  which  they  resemble. 
Those  most  frequently  used  are  seen  in  Figs.  545,  546,  547,  and  548. 


Fig.  545.  Fig.  546.  Fig.  547.  Fig.  548. 


V-shaped  incision.  H-shaped  incision.  L-shaped  incision.  T-shaped  incision. 

In  making  these  incisions,  the  second  simple  incision  should  always 
terminate  in  the  first,  and  not  begin  from  it ; and,  that  the  blood  may 
not  conceal  the  place  where  the  second  incision  is  to  be  located,  the 
first  and  lower  one  ought  to  be  made  first.  Their  object  is  to  expose 
the  parts  beneath  the  integuments  more  fully  than  could  be  effected 
with  simple  incisions.  They  form  flaps  of  greater  or  less  size,  accord- 
ing to  their  extent,  which  are  dissected  from  the  deeper  tissues  and 
raised  up ; thus  affording  an  opportunity  to  the  surgeon  to  gain  free 
access  to  and  remove  morbid  structures, 
however  deeply  placed  they  may  be. 

A large  extent  of  surface  of  deeply- 
seated  parts  may  also  be  exposed  by 
the  crucial  incision  seen  in  Fig.  549, 
which  consists  of  two  simple  incisions 
crossing  each  other  at  right  angles. 

In  many  cases  of  large  tumors  it 
becomes  necessary  to  remove  a portion  of  the  integuments  entirely, 
so  that  the  resulting  flaps  may  just  cover  the  parts  beneath ; this  is 
accomplished  by  an  elliptical  incision  such  as  is  seen  in  Fig.  550 ; it 
is  formed  by  joining  two  curved  incisions  at  their  extremities.  The 
semilunar  incision  may  be  also  used  for  the  same  purpose  as  the 


Fig.  549. 


Fig.  550. 


Crucial  incision.  Elliptical  and  semilunar 
incisions. 


Fig.  543. 


Fig.  544. 


Straight  incision.  Curved  incision. 


600 


BLOODLETTING. 


elliptical,  but  it  is  now  rarely  employed ; it  consists  of  two  concentric 
curved  incisions,  joined  together  at  their  ends,  as  seen  in  Fig.  550. 

There  are  surgeons  who  prefer  the  scissors  for  making  certain  inci- 
sions ; Malgaigne  always  chooses  them  when  the  parts  may  be  divided 
at  one  stroke. 

Subcutaneous  incisions  are  now  frequently  had  recourse  to  for  the 
purpose  of  shielding  the  parts  divided  from  contact  with  the  atmo- 
sphere while  the  reparative  process  is  going  on,  which  experience  has 
shown  will  occur  without  inflammation.  Th§  instrument  employed 
for  this  operation  is  seen  in  Fig.  551.  It  consists  of  a narrow  blade 

Fig.  551. 

— — * =====  ~‘,r  \ 

Knife  for  subcutaneous  incisions 

with  a long,  slender  stem  connecting  it  with  the  handle.  In  using 
the  knife,  the  blade  is  introduced  flatwise  beneath  the  skin,  obliquely, 
under  the  part  to  be  divided,  when  its  edge  is  directed  against  it,  and 
by  a slow  sawing  motion  the  section  is  effected.  The  instrument  is 
then  withdrawn,  and  the  little  wound  hermetically  sealed,  either  with 
a small  piece  of  adhesive  plaster,  or  a bit  of  charpie  soaked  in  blood 
or  collodion. 


CHAPTER  XI. 

BLOODLETTING. 

Bloodletting  is  an  operation  performed  for  the  purpose  of  dimi- 
nishing the  quantity  of  blood  in  the  system,  with  a view  of  relieving 
or  curing  diseases. 

It  may  be  drawn  from  the  arteries,  veins,  or  capillaries;  in  the  first 
two  instances  the  bleeding  is  said  to  be  general,  and  in  the  latter,  local. 

The  former  plan,  now  almost  abandoned,  is  had  recourse  to  when 
the  amount  of  blood  to  be  drawn  is  large,  and  a decided  effect  is  to 
be  made  upon  the  system ; and  the  latter,  when  the  object  is  rather 
to  deplete  a certain  organ  or  part,  without  reference  to  the  system  at 
large. 

There  are  cases,  however,  where  both  methods  may  be  employed 
together  with  advantage. 


SECTION  I. 

GENERAL  BLEEDING. 

Venesection,  or  Phlebotomy. — In  former  times  bleeding  was 
performed  upon  most  of  the  large  veins,  the  operation  in  each  par- 
ticular case  being  supposed  to  possess  some  peculiar  advantages ; but 


GENERAL  BLEEDING. 


601 


at  present  the  physician,  knowing  that  the  general  character  of  the 
effects  of  loss  of  blood  is  the  same  whether  a vein  be  opened  in  the 
arm,  in  the  neck,  or  in  the  leg,  selects  the  most  convenient  place 
for  the  operation,  and  general  experience  has  decided  that  to  be  the 
bend  of  the  elbow.  Here  the  veins  are  moderately  large,  superficial, 
and  easily  dilatable  by  a bandage  placed  upon  the  arm. 

By  reference  to  the  annexed  wood-cut,  Figs.  552  and  553,  showing 
the  veins  of  the  bend  of  the  elbow,  it  will  be  seen  that  there  are  five 


vessels  from  which  the  surgeon  may  draw  blood : the  radial  vein  (1) 
is  on  the  outer  side  of  the  forearm,  between  the  skin  and  superficial 
fascia,  is  crossed  by  (17)  the  spiral  cutaneous  nerve,  a branch  of  the 
musculo-spiral,  and  is  surrounded  by  a large  number  of  nervous 
filaments ; the  median  (8)  is  about  midway  of  the  upper  part  of  the 
forearm,  and  divides  above  into  two  branches,  one  going  to  the  cepha- 
lic (2),  forming  the  median-cephalic  (10),  and  the  other  to  the  basilic, 
forming  the  median-basilic  (11);  the  anterior  (3)  and  posterior  (4)  ulna 
are  upon  the  inner  side  of  the  arm,  and  join  above  in  a common  trunk 
(5),  which  empties  into  the  basilic;  the  median-basilic  crosses  the 
brachial  artery,  separated  from  it  by  a slip  of  fascia  from  the  tendon 
of  the  biceps  (13)  at  the  point  marked  by  the  figure  12,  which  rests 
upon  the  deep  fascia ; in  Fig.  553  this  fascia  is  turned  back,  exposing 
the  artery  beneath ; the  internal  cutaneous  nerve  (15)  divides  into 
several  branches,  which  pass  across  the  median-basilic ; the  external 
cutaneous  nyve  (14)  pierces  the  deep  fascia,  and,  dividing  into  two 
branches,  passes  behind  the  median-cephalic,  which  is  surrounded  by 
several  nervous  filaments;  the  intercosto-humeral  cutaneous  nerve  (16) 
runs  along  the  outer  side  of  the  basilic. 


Fig.  552, 


Fig.  553, 


Anatomical  relation  of  the  veins  in  the  bend  of  the  elbow. 


602 


BLOODLETTING. 


The  veins  are  more  or  less  surrounded  with  nervous  filaments,  so 
that  it  will  be  impossible  to  avoid  wounding  some  of  them  in  vene- 
section, nor  does  experience  teach  us  that  .it  is  of  much  consequence  if 
they  are.  The  proximity  of  the  median-basilic  to  the  brachial  artery 
should  put  us  on  our  guard  when  opening  that  vein;  and,  indeed,  if 
there  is  any  choice  offered,  it  should  be  avoided  altogether.  The  pos- 
terior ulna  is  sometimes  quite  large,  and  offers  then  the  most  eligible 
spot  for  the  operation;  though,  upon  the  whole,  the  median-cephalic 
will  be  the  safest  and  most  convenient  vein. 

If  a sudden  impression  is  desired  to  be  made  upon  the  system,  and 
syncope  is  induced,  the  patient  should  be  b^ed  in  the  erect  posture; 
while,  on  the  contrary,  if  the  full  depletive  effects  of  the  operation  are 
sought,  he  must  lie  down. 

After  the  surgeon  has  selected  the  vein  he  intends  to  open,  which  is 
ordinarily  visible  through  the  skin  (though  in  children  and  corpulent 
persons  it  is  not  always  so,  and  then  the  sense  of  touch  will  enable  us 
to  make  out  the  position  of  the  vessel),  the  circular  bandage  is  placed 
around  the  arm,  some  distance  above  the  elbow;  this  consists  of  a 
strip  of  muslin  one  and  a half  inch  wide  and  a yard  long,  and  is 
applied  by  placing  its  body  upon  the  front  of  the  arm,  conducting  its 
extremities  around  the  limb,  and  finally  bringing  them  forwards  again 
to  be  tied  in  a single  bow-knot  upon  the  outer  side  of  the  arm. 

The  bandage  should  be  drawn  sufficiently  tight  to  arrest  the  circu- 
lation in  the  veins  without  disturbing  that  in  the  arteries;  the  sur- 
geon then  takes  the  lancet  by  its  blade  between  the  thumb  and  index 
finger,  while  the  middle  finger,  resting  upon  the  forearm,  supports  the 


drawn  by  slightly  elevating  the  point  to  enlarge  the  orifice  to  the 
desired  extent.  If  the  operation  is  well  done,  the  blood  will  flow 
in  a continuous  stream,  and  should  be  caught  in  a common  basin,  or 
in  one  of  those  graduated  vessels  especially  made  for  this  purpose, 
and  called  a “ palette.” 

Should  the  blood  uot  flow  freely  enough,  the  patient  may  be  directed 
to  grasp  something  in  his  hand,  and  to  close  and  relax  the  fingers 
alternately.  The  exit  of  the  blood  may  be  hindered  by  the  loss  of 
parallelism  between  the  incision  in  the  skin  and  wall  of  the  vein, 
caused  by  some  movement  on  the  part  of  the  patient ; to  remedy  this 
the  limb  should  be  restored,  as  nearly  as  possible,  to  the  position  in 
which  it  was  when  the  incision  was  made ; or  a little  clot  of  blood  or 


Fig.  554. 


hand,  as  seen  in  Fig.  554 ; with 
the  left  hand  the  forearm  is 
grasped  in  such  a manner  that 
the  corresponding  thumb  may 
be  used  to  steady  the  vein,  while 
it  is  being  punctured.  The  point 


of  the  thumb-lancet  is  now  thrust 
forwards  obliquely,  by  simply 
extending  the  thumb  and  fin- 


of  further  resistance  to  the  progress  of  the  instrument,  and  then  with- 


GENERAL  BLEEDING. 


603 


granule  of  fat  may  come  between  the  lips  of  the  little  wound ; they 
must  be  removed  with  the  point  of  a probe  or  a pair  of  forceps.  In 
case  the  ligature  upon  the  arm  is  drawn  so  tight  as  to  obstruct  the 
passage  of  the  blood  from  the  arteries  to  the  veins,  it  must  be 
promptly  loosened  until  the  blood  issues  freely.  The  desired  amount 
of  blood  having  been  drawn,  the  surgeon  places  his  left  thumb  over 
the  incision,  removes  the  circular  bandage  from  the  arm,  which  should 
be  cleansed  from  blood  with  a moist  sponge,  and  slips  beneath  the 
thumb  a small  compress  an  inch  square  by  half  an  inch  thick,  made 
of  a piece  of  linen  folded  ; the  compress  is  secured  in  position  by  the 
figure  of  8 bandage  of  the  elbow,  taking  care  to  draw  its  lower  con- 
volutions tighter  than  the  upper  ones  that  efficient  pressure  may  be 
made  upon  these  veins  anastomosing  with  the  vessel  opened.  The 
arm  is  now  flexed  at  a right  angle,  and  supported  in  a sling  depend- 
ing from  the  neck,  for  thirty-six  or  forty-eight  hours,  when  the  wound 
will  be  found  cicatrized. 

Should  it  be  necessary  to  repeat  the  bleeding  within  the  twenty-four 
hours,  the  same  vein  may  be  again  opened  with  the  point  of  a probe ; 
or  if  this  has  been  anticipated,  a little  piece  of  simple  cerate  placed 
between  the  margins  of  the  incision  will  prevent  its  healing,  upon  the 
removal  of  which  the  blood  will  flow  freely ; but  it  is  a better  plan 
always  to  make  a fresh  incision. 

The  spring-lancet  is  sometimes  employed  in  venesection  ; the  instru- 
ment consists  of  a blade  or  fleam  inclosed  in  a metallic  case,  and  acted 
upon  by  a strong  spring;  when  in  use  the  blade  is  drawn  up  with 
the  handle  projecting  above  it  until  its  point  is  above  the  lower  edge 
of  the  case,  in  which  position  it  is  held  by  a trigger,  and  not  permitted 
to  be  driven  down  unless  the  button  upon  the  side  of  the  case  is 
pressed  upon.  The  arm  having  been  prepared  in  the  same  manner  as 
in  the  previous  case,  if  the  vein  is  superficial  the  edge  of  the  fleam 
should  be  held  a little  above  the  skin ; but,  on  the  contrary,  if  it  is 
deep  seated,  the  point  of  the 
fleam  ought  to  touch  the  sur- 
face, in  order  that  the  cavity 
of  the  vessel  may  be  surely 
reached;  the  blade  is  then 
driven  into  the  vein  obliquely 
by  pressing  the  button  of 
the  spring,  and  quickly  with- 
drawn. 

Some  accidents  have  fol- 
lowed venesection  which  re- 
quire notice  in  this  place,  as 
great  alarm  has  often  been  caused  the  patient,  where  there  has  been 
no  occasion  for  it,  by  some  unusual  complication  of  little  moment ; 
for  instance,  the  cutaneous  incision  may  be  very  narrow,  or  lose  its 
parallelism  with  the  perforation  in  the  wall  of  the  vein,  so  that  the 
blood  escapes  into  the  cellular  tissue,  and  gives  rise  to  an  ecchymosis 
several  inches  around  the  puncture ; the  blood  in  this  case  will  be 
absorbed  in  three  or  four  days.  From  the  same  causes  the  blood  may 


Fig.  555. 


604 


BLOODLETTING. 


coagulate  around  the  vein,  forming  a tumor  called  a thrombus,  which 
also  usually  disappears  without  any  bad  consequence,  though  it  may 
excite  inflammation  and  suppuration,  and  demand  the  use  of  the  lancet 
to  evacuate  the  pus. 

As  the  veins  are  surrounded  more  or  less  with  nervous  filaments, 
some  pain  may  be  caused  in  irritable  subjects,  which  may  be  re- 
moved by  the  application  of  the  watery  solution  of  opium;  convul- 
sions and  tetanus  have  been  stated  to  have  originated  from  the 
same  cause. 

As  inflammation  of  the  lips  of  the  wound,  phlegmon,  erysipelas, 
and  angeioleucitis,  may  happen  from  special  causes  in  any  sort  of 
wound,  they  are  simply  mentioned  here  as.  having  been  occasionally 
seen  to  follow  venesection. 

Phlebitis  is  always  a serious  complication  of  wounds,  and  may 
occur  in  phlebotomy;  the  veins  become  hard  like  cords,  and  the 
whole  limb  oedematous.  The  proper  remedies  for  phlebitis  are  the 
application  of  leeches,  and,  after  their  removal,  narcotic  poultices. 
It  has  been  recommended  to  tie  the  vein  above  the  puncture  to  pre- 
vent the  pus  getting  into  the  circulation ; with  the  same  view  Aber- 
nethy  advised  the  vessel  to  be  divided  instead  of  ligatured  ; free  inci- 
sion at  the  seat  of  the  wound,  combined  with  pressure,  will  also  be 
found  advantageous. 

Puncture  of  the  tendon  of  the  biceps  muscle  has  also  been  pointed 
out  as  a redoubtable  accident  upon  insufficient  grounds. 

Wounding  the  brachial  artery  in  venesection  has  often  occurred, 
and  may  result  in  either  traumatic  aneurism,  or  aneurismal  varix; 
the  blood,  in  the  former  instance,  being  poured  out  into  the  surround- 
ing cellular  tissue,  and  in  the  latter  into  the  cavity  of  the  vein 
through  the  orifice  made  in  its  posterior  wall  by  the  lancet.  In  the 
aneurismal  varix  the  blood  will  issue  in  jets,  or  per  saltum,  as  it  is 
called,  and  be  of  a scarlet  color,  and  somewhat  frothy.  Pressure  upon 
the  brachial  artery  above  arrests  the  hemorrhage  at  once;  but  not  at 
all,  or  very  slowly,  if  the  pressure  is  made  upon  the  entire  circum- 
ference of  the  limb.  The  pressure  should  be  exerted  upon  the  artery 
in  the  axilla,  that  no  mistake  can  occur  from  its  bifurcation  taking 
place  high  up  the  arm.  From  these  symptoms,  if  it  should  be  ascer- 
tained that  the  artery  has  actually  been  pierced  with  the  lancet,  the 
arm  should  be  inclosed  in  a roller  bandage  from  the  fingers  to  the 
shoulder,  and  a graduated  compress  placed  over  the  puncture,  with 


Mode  of  arresting  hemorrhage  from  the  brachial  artery  at  the  bend  of  the  elbow,  after  venesection. 

its  apex  downward,  in  the  manner  shown  in  Fig.  556 ; a,  is  the 
artery,  and  b,  b the  compress.  To  sustain  the  compress,  apply  over 
it  a figure  of  8 bandage  pretty  firmly. 


GENERAL  BLEEDING. 


605 


By  this  treatment  it  sometimes  happens  that  the  wound  in  the 
artery  cicatrizes  in  three  or  four  days,  and  no  further  trouble  is  expe- 
rienced; under  other  less  favorable  circumstances,  a pulsating  tumor 
is  formed,  which  will  demand  an  incision  to  be  made  over  the  bleed- 
ing artery,  and  a ligature  applied  above  and  below  the  wound. 

Both  the  salvatella  and  cephalic  veins  of  the  hand  have  been 
opened  in  venesection.  A circular  bandage  placed  around  the  wrist 
with  sufficient  firmness,  will  cause  them  to  swell  sufficiently,  so  as 
to  be  easily  punctured  with  the  lancet.  Should  the  ligature  not 
render  them  prominent,  the  hand  may  be  soaked  a short  time  in  warm 
water.  There  are  no  arteries  in  the  way,  and  the  only  caution  neces- 
sary is  to  avoid  wounding  the  sheaths  of  the  extensor  tendons.  When 
the  radial  artery,  instead  of  following  its  usual  course,  mounts  over 
the  extensors  of  the  thumb,  it  will  be  found  running  parallel  with  the 
cephalic  vein. 

The  cephalic  vein  of  the  arm  is  found  between  the  deltoid  and 
pectoralis  major,  and  may  be  exposed  by  an  incision  an  inch  long  in 
front  of  the  shoulder,  over  the  inter-muscular  space.  Yelpeau  re- 
commends the  vein  to  be  sought  just  above  the  inner  condyle,  where 
it  is  more  superficial ; bleeding  from  this  vessel  is  rarely  ever  prac- 
tised at  present. 

It  was  formerly  recommended,  in  certain  cases  of  cephalic  disease, 
to  bleed  from  the  external  jugular  which  crosses  the  neck  obliquely, 

' lying  between  the  superficial 
fascia  and  the  platysma  myoid 
muscle,  and  empties  in  the  sub- 
clavian behind  the  clavicle. 

The  operation  is  performed  by 
placing  over  the  vein  a com- 

I press  just  above  the  clavicle, 
and  confining  it  in  the  position 
with  a cravat,  the  body  of 
which  is  laid  over  the  com- 
press, and  its  tails  tied  beneath 
the  axilla  of  the  opposite  side, 
in  order  to  prevent  the  return 
of  the  blood  in  the  vessel.  (Fig. 

558.)  The  point  that  should 
be  selected  for  the  puncture  is 
just  below  the  middle  of  the 
vein,  where  the  vessel  is  largest, 

I and  surrounded  with  fewer  nervous  filaments.  The  vein  must  be 
steadied  by  the  thumb  (Fig.  557),  while  the  thumb-lancet,  held  in 
the  right  hand  in  the  manner  we  have  described,  is  thrust  into  its 
cavity  in  an  oblique  direction,  so  as  to  cut  the  muscular  fibres  of  the 
platysma  at  right  angles  to  their  course,  that  their  retraction  may 
allow  a sufficient  opening  for  the  blood  to  flow  out  freely.  A card 
or  piece  of  tin,  bent  in  the  shape  of  a gutter,  and  placed  below  the 
point  of  puncture,  will  conduct  the  blood  away  into  a vessel  ready 
at  hand  to  receive  it. 


Fig.  557. 


606 


BLOODLETTING. 


Should  the  blood  not  issue  with  sufficient  rapidity,  the  patient  may 
be  directed  to  perform  the  movements  of  mastication,  which  will  force 
the  blood  from  the  deeper  veins  into  the  more  superficial  ones. 

To  arrest  the  bleeding,  place  the  finger  over  the  puncture,  remove 
the  compress  and  bandage  at  first  applied,  and  put  a compress  upon  the 
wound  to  which  it  must  be  secured  by  a cravat,  the  base  of  which  is 
laid  upon  the  neck  and  shoulder  of  the  opposite  side,  its  tails  crossed 
over  the  compress,  and  finally  tied  together  beneath  the  axilla  of  the 
side  upon  which  the  vein  was  punctured. 

The  veins  of  the  foot  are  small,  and  therefore  ineligible  for  vene- 
section; by  their  junction,  however,  they  form  two  large  trunks,  the 
internal  and  external  saphenous,  which  may  be  opened  with  the 
lancet.  The  external  saphenous  is  situated  between  the  external 
malleolus  and  the  tendo-Achillis,  and  is  in  relation  with  a nerve  of 
the  same  name ; the  internal  saphenous  lies  upon  the  inner  malleolus 
between  the  skin  and  periosteum  ; this  vein  is  larger  than  the  former, 
and  is  generally  selected  for  the  operation. 

To  enlarge  the  veins  about  the  ankle,  the  foot  must  be  placed  in  warm 
water,  and  a circular  bandage  applied  to  the  leg  three  or  four  inches 
above  the  malleoli,  then  the  most  prominent  vessel  being  selected,  it 
is  steadied  with  the  thumb  of  the  left  hand  which  grasps  the  foot, 
while  the  point  of  the  lancet  is  shoved  into  its  interior  with  the  fingers 
of  the  right  hand,  almost  parallel  with  the  vessel,  in  order  to  avoid 
penetrating  the  periosteum  or  bone.  The  flow  of  blood  may  be  in- 
creased by  keeping  the  foot  immersed  in  warm  water  contained  in  a 
pail,  though  it  has  the  disadvantage  of  interfering  with  a correct 
estimate  of  the  amount  of  blood  drawn;  the  bleeding  may  also  be 
accelerated  by  the  patient  moving  his  toes. 

When  a sufficiency  of  blood  has  been  obtained,  the  circular  bandage 
is  removed,  and  a compress  confined  over  the  wound  with  the  figure 
of  8 bandage  of  the  ankle. 

If  the  point  of  the  lancet  should,  by  any  accident,  penetrate  the 
bone,  the  wound  may  be  enlarged  a little  and  the  point  removed ; 
though  should  the  little  fragment  of  metal  be  permitted  to  remain  it 
will,  perhaps,  cause  a phlegmon  to  form,  and  be  finally  eliminated 
with  the  pus. 

Arteriotomy. — The  only  artery  that  has  been  opened  in  later 
times  for  surgical  depletion  is  the  temporal,  and  that  is  now  nearly 
abandoned  by  most  surgeons;  the  ancients,  besides  this  one,  did  not 
fear  to  cut  the  mastoid,  and  even  the  radial. 

If  it  is  ever  desirable  to  perform  this  operation  upon  an  artery,  the 
anterior  branch  of  the  temporal  is  of  sufficient  size  to  afford  the 
requisite  amount  of  blood,  besides  possessing  the  advantages  of  being 
superficial  and  easily  compressed  upon  the  temporal  bone  to  check 
the  hemorrhage;  and  there  are  no  important  parts  adjacent  that  we 
need  fear  wmunding. 

The  operation  is  performed  either  with  a lancet  or  a bistoury  (Fig. 
558).  The  artery  being  held  by  the  index  and  middle  fingers,  an  incision 
is  made  three-fourths  of  an  inch  long,  at  right  angles  with  its  course, 


GENERAL  BLEEDING. 


607 


Fig.  558. 


dividing  half  the  diameter,  or  thereabouts,  Fig-  559. 

of  the  vessel.  The  object  of  this  is  to  pre- 
vent the  retraction  of  the  extremities  of  the 
artery,  which  would  be  likely  to  defeat  the 
aim  of  the  surgeon,  inasmuch  as  the  orifices 
would  then  be  drawn  into  the  cellular 
tissue,  in  which  the  blood  would  coagulate 
and  seal  them  up. 

When  the  bleeding  has  gone  far  enough, 
the  instrument  is  used  again  to  cut  the 
vessel  completely  through  to  permit  the 
divided  ends  to  retract;  a compress  is 
placed  over  the  wound  and  supported  by 
a roller  bandage,  as  seen  in  Fig.  559. 

The  artery  is  usually  obliterated  in  eight 
or  ten  days,  though  a traumatic  aneurism 
does  sometimes  result,  requiring  the  ends  of  the  artery  to  be  tied 


Bandage  and  compress  applied  after 
arteriotomy. 


608 


BLOODLETTING. 


SECTION  II. 

LOCAL  BLEEDING. 

Local  bleeding  is  generally  performed  over,  or  as  near  to  the  ; 
diseased  part  as  possible,  for  the  purpose  of  abstracting  blood  directly  I 
from  it.  In  some  cases,  from  necessity,  the  point  upon  which  the  ope- 
ration is  performed  will  be  more  or  less  remote  from  the  diseased 
organ,  as  in  the  abstraction  of  blood  from  the  temple  in  diseases  of 
the  eye,  and  from  the  hemorrhoidal  vessels  in  affections  of  the  brain. 
The  first  method  is  by  far  the  most  serviceable  and  the  one  commonly 
employed  in  surgical  practice. 

Local  depletion  may  be  effected  in  two  •modes : first,  by  cupping ; ! 
and  second,  by  leeching. 

1.  Cupping  consists  in  the  application  to  the  skin  of  a bell-shaped 
vessel,  now  made  of  glass,  technically  called  a “ cup,”  by  rarefying  the 
air  contained  within  it  by  means  of  heat,  or  a sort  of  air-pump.  In 
this  way  the  integuments  are  made  turgid  and  red,  and  are  forced  up 
some  distance  into  the  cup  by  atmospheric  pressure. 

This  action  produces  a derivative  effect  by  drawing  the  blood  from 
the  morbid  tissues  beneath,  whose  capillaries  are  thereby  placed  under 
more  favorable  circumstances  for  restoration  to  health ; this  is  called  ! 
dry  cupping. 

If  a more  decided  and  permanent  derivative  effect  is  required,  the 
integuments  are  scarified  so  that,  upon  the  reapplication  of  the  cup,  the 
blood  will  flow  out  from  the  capillaries  freely,  constituting  wet  cupping,  1 
or,  as  it  is  sometimes  named,  cut  cups. 

Cupping  glasses  are  usually  supplied,  by  surgical  instrument  makers, 
of  different  sizes,  holding  from  one  to  four  ounces,  destined  for  appli- 
cation to  the  various  localities  of  the  body,  upon  all  of  which  it  would 
be  impossible  to  put  glasses  of  the  same  dimensions.  Should  these 
not  be  at  baud,  however,  the  ordinary  wineglass  or  tumbler  will  an- 
swer as  a good  substitute. 

The  person  to  be  cupped  should  be  placed  in  a convenient  position, 
and  arranged  in  such  a manner  that  his  clothes  may  not  be  soiled  with 
the  blood ; the  skin  upon  which  the  operation  is  to  be  performed  is 
then  bared  and  wiped  clean  with  a sponge  dipped  in  hot  water,  which 
will  at  the  same  time  tend  to  congest  the  capillaries,  and  thus  render 
the  bleeding  freer.  The  operator  takes  a cup  in  his  hand,  and  either 
dips  it  in  hot  water,  or  holds  it  for  two  or  three  seconds  over  the 
flame  of  a spirit  lamp,  to  rarefy  the  air  in  its  interior,  and  quickly 
claps  it  upon  the  skin ; a better  plan  is  to  moisten  the  interior  of  the 
glass  with  alcohol,  or  put  into  it  a thin  piece  of  paper  dipped  in  that 
fluid  and  set  fire  to  before  the  cup  is  applied. 

The  integuments  will  rise  immediately  into  the  mouth  of  the  glass, 
and  present  a red,  turgid  appearance. 

A second  mode  of  rarefying  the  air  inside  the  cup  is  with  an  air- 
pump,  which  is  made  with  a socket  at  its  extremity  to  fit  the  nipple- 
like projection  upon  the  tops  of  the  glasses;  the  projection  is  pierced 
with  a small  aperture  and  covered  with  a little  slip  of  gold  beaters 


LOCAL  BLEEDING. 


609 


skin  or  oiled  silk  to  serve  as  a valve,  or,  as  a better  arrangement,  still 
it  bears  a stopcock,  as  seen  in  Fig.  560.  With  this  instrument  the 
air  is  gradually  exhausted  from  the  glass  by  repeated  strokes  of  the 
piston,  until  the  skin  is  sufficiently  turgid,  when  the  stopcock  must 
be  turned,  and  the  air-pump  removed. 

To  do  away  with  the  inconveniences  of  the  air-pump,  among  which 
we  may  mention  as  the  chief  its  liability  to  get  out  of  order,  it  has 
been  suggested  to  attach  an  India-rubber  ball  to  the 
top  of  the  cup  and  make  the  vacuum  with  that,  by  grasp- 
ing the  ball  in  the  palm  of  the  hand  and  alternately 
compressing  and  relaxing  the  hold  upon  it  (Fig.  561). 

Whichever  plan  is  pursued,  the  glasses  must  not  be 
exhausted  too  much,  for  if  they  are,  their  edges  will  pro- 

Fig.  561. 


Fig.  560. 


Mode  of  attaching  an 
air-pump  to  the 


Cupping-glass  with  India-rubber  ball  attached.  cupping-glass. 

bably  bruise  the  skin,  prevent  the  flow  of  blood,  and  at  the  same  time 
cause  considerable  pain. 

To  remove  the  cup  it  will  be  necessary  simply  to  cant  it  a little  to 
one  side,  and  with  the  tip  of  the  finger  press  the  integuments  away 
from  any  point  of  its  rim,  which  will  permit  the  entrance  of  air  into 
the  glass  and  destroy  the  vacuum. 

In  applying  cut  cups  the  same  methods  are  pursued  as  described 
above,  and  when  the  skin  is  sufficiently  con- 
gested the  glass  is  removed  and  incisions  are 
made  upon  the  reddened  surface ; this  may  be 
accomplished  either  with  the  lancet,  bistoury, 
or  scarificator,  the  latter  being  the  most  expedi- 
tious and  least  painful  manner.  This  instru- 
ment, as  seen  in  Fig.  562,  consists  of  a square 
metallic  case  containing  from  twelve  to  fifteen 
broad,  sharp  blades,  attached  to  two  stems  of 
metal  revolving  through  a quarter  of  a circle, 
and  driven  by  a strong  spring;  the  depth  of 
the  cut  may  be  graduated  by  raising  or  depress- 
ing the  blades  with  the  screw-head  seen  upon 
the  top  of  the  instrument;  the  blades  are  drawn  into  the  case  by 
39 


Fig.  562. 


Scarificator. 


610 


BLOODLETTING. 


pulling  back  the  lever  placed  by  the  side  of  the  screw-head;  the  lever 
is  held  by  a catch. 

The  instrument  thus  arranged  is  ready  for  use,  and  is  laid  flat  upon 
the  surface  to  be  scarified ; then,  by  exercising  pressure  with  the 
thumb  upon  the  little  button  seen  upon  its  side,  the  trigger  is  sprung, 
and  the  blades  driven  into  the  skin. 

After  the  incisions  are  made,  the  glasses  are  again  applied,  when 
the  blood  will  readily  flow  into  them  in  quantity  varying  with  the 
size  of  the  cups  and  the  vascularity  of  the  parts ; perhaps,  on  an 
average,  an  ounce  will  be  drawn  by  each  cup,  but  should  it  be  neces- 
sary these  may  be  reapplied  several  times,  until  the  desired  amount  of 
blood  is  obtained.  A basin  of  warm  water  should  be  at  hand,  and 
two  or  three  soft  towels  and  sponges;  the  cups,  one  after  another,  are 
then  seized  in  the  fingers,  and  having  been  depressed  upon  the  side, 
are  quickly  removed  with  a sort  of  scooping  motion  to  catch  the 
clotted  blood,  assisting  the  operation  with  a sponge  held  in  the  oppo- 
site hand.  In  this  manner  the  patient’s  clothes  will  not  be  soiled  at 
all.  The  surface  may  be  now  gently  cleansed  with  warm  water,  and 
dried  with  a towel;  generally,  no  dressing  will  be  required,  but 
should  the  incisions  be  sore  or  painful,  a soft  rag,  moistened  in  glyce- 
rine, or  water-dressings,  will  be  the  most  appropriate  applications. 

Cups  should  not  be  placed  over  osseous  projections,  nor  indeed 
upon  any  surface  where  there  is  not  a sufficient  amount  of  soft  tissue 
to  give  them  ample  support.  There  are  other  situations  where  their 
application  is  manifestly  impracticable — as  in  the  interior  of  cavities, 
upon  the  eyelids,  testicles,  &c.  Yet  even  these  difficulties  have  been 
surmounted  in  some  degree  by  the  cups  of  Toirac,  which  consist  of 
long,  narrow  glasses,  connected  by  an  elastic  tube  with  an  air-pump, 
that  are  capable  of  being  applied  to  the  bottom  of  any  cavity  what- 
ever. M.  Sarlandi&re  invented  an  instrument  called  a Idellomkre, 
which  combines  in  its  construction  the  air-pump  cupping-glass  with 
the  scarificator,  so  that  the  whole  operation  of  cupping  can  be  accom- 
plished in  one  application  of  the  instrument. 

Prof.  Simpson,  of  Edinburgh,  has  used  an  instrument  for  cupping 
the  interior  of  the  uterus  in  amenorrhoea ; it  consists  of  an  air-pump 
and  a perforated  tube,  sufficiently  large  to  hold  several  drachms  of 
blood,  connected  together.  The  tube  is  curved,  and  has  a ring  of 
gutta-percha  upon  it,  rounded  in  such  a manner  as  to  accurately  close 
the  os  uteri  when  the  point  of  the  instrument  is  in  the  cavity  of  that 
organ. 

M.  Junod  recommended  the  use  of  cups  sufficiently  large  to  inclose 
portions  of  the  body,  as  the  leg  or  arm.  He  employed  a copper  cylin- 
der, in  which  the  limb  was  to  be  placed,  and  rendered  air-tight  by  a 
strip  of  India-rubber  surrounding  the  limb  and  the  upper  end  of  the 
cylinder ; to  the  latter  an  air-pump  is  attached  to  make  the  vacuum, 
which  can  be  regulated  by  an  instrument  connected  with  the  cylinder. 
With  this  apparatus  the  most  powerful  and  rapid  derivative  effects 
can  be  obtained,  that  syncope  may  be  induced  in  a brief  space  of 
time. 

Leeching. — For  the  purpose  of  local  depletion,  leeches,  in  many 


LOCAL  BLEEDING. 


611 


cases,  offer  decided  advantages ; indeed,  some  parts  of  the  body,  from 
their  situation  within  the  interior  of  the  natural  cavities,  peculiarity 
of  form,  or  from  diseased  condition  of  their  surfaces,  cannot  be  easily 
depleted  in  any  other  manner.  There  are  two  kinds  of  leeches  em- 
ployed in  this  country,  which  it  is  necessary  to  be  able  to  distinguish, 
as  they  differ  materially  in  the  amount  of  blood  which  they  are  capa- 
ble of  abstracting.  The  foreign  leeches  ( Sanguisuga  officinalis  and 
medicinalis ) are  gathered  in  Sweden,  and  several  parts  of  the  south  of 
Europe,  from  the  marshes  and  running  streams,  and  imported  from 
London  and  Paris.  They  vary  from  two  to  four  inches  in  length, 
and  are  marked  upon  their  backs,  which  vary  from  a blackish  to  a 
grayish-green,  with  six  longitudinal  ferruginous  stripes,  the  four  late- 
ral ones  being  interrupted  with  black  spots  ; the  belly,  in  one  variety, 
is  of  a yellowish-green  color,  bordered  with  longitudinal  black  stripes ; 
in  the  other,  of  a green  color,  bordered  and  spotted  with  black.  Each 
of  these  animals  will  draw  rather  more  than  a half-ounce  of  blood. 

The  indigenous  leech  [Hirudo  decora)  is  usually  from  two  to  three 
inches  long,  though  it  sometimes  attains  a length  of  five  inches ; its 
back  is  of  a deep  green  color,  with  three  longitudinal  rows  of  square 
spots,  and  the  belly  of  a brownish-orange  color,  irregularly  spotted 
with  black.  The  animal  does  not  make  so  large  a wound  in  the  skin 
as  the  former,  and  it  requires  at  least  six  of  them  to  extract  one  ounce 
of  blood. 

The  mouth  of  the  leach  is  placed  in  the  centre  of  the  anterior  disk, 
and  is  composed  of  three  cartilaginous  jaws,  each  armed  with  two 
rows  of  fine  teeth  meeting  in  such  a manner  as  to  make  a triangular 
wound  in  the  integuments. 

In  applying  the  animals  to  the  skin,  care  should  be  taken  to  have 
it  well  cleansed  of  all  foreign  matters  clinging  to  it  either  from  the 
applications  that  may  have  been  used,  or  from  the  secretions;  the 
hairy  parts  of  the  body  should  be  thoroughly  shaved,  so  that  the  hair 
may  neither  interfere  with  the  action  of  the  leeches  nor  become 
clotted  with  blood. 

The  leeches  are  then  put  on  inclosed  in  a tumbler ; or,  if  there  are 
many  of  them,  laid  first  upon  a napkin  spread  upon  the  palm  of  the 
hand,  and  then  clapped  to  the  skin,  the  fingers  being  used  to  hold  the 
edges  of  the  cloth  all  around,  so  that  they  may  not  escape.  Vigorous 
leeches  will  generally  take  hold  upon  the  skin'  without  delay ; but 
should  they  not  do  so,  milk,  cream,  or  sweetened  water  smeared  over 
the  surface  will  almost  always  tempt  them  to  bite;  some  persons 
obtain  a little  blood  from  the  tip  of  the  finger  by  pricking  it  with  a 
needle,  which  they  rub  upon  the  skin  with  the  same  object. 

An  increased  activity  may  be  excited  in  the  leeches  by  covering 

I;  them  with  a cupping-glass,  and  rarefying  the  air  contained  in  it  by  a 
few  strokes  of  the  air-pump.  Another  mode  recommended  as  very 
efficient  is  to  put  the  leeches  first  in  a tumbler  half  full  of  cold  water, 
and  by  a quick  movement  invert  it  over  the  part  to  be  depleted ; the 
animals  will  seek  the  warm  skin  immediately,  and  quickly  attach 
themselves  to  it,  when  the  water  may  be  permitted  to  run  from  the 
glass  upon  cloths  placed  to  receive  it. 


612 


BLOODLETTING. 


To  bring  leeches  in  contact  with  the  interior  cavities,  the  vagina  or 
rectum,  for  instance,  a speculum  should  be  first  introduced,  then  a 
leech  is  placed  in  a glass  tube,  or  one  formed  from  paper  or  a card ; 
and  when  its  point  is  at  the  spot  where  the  animal  is  to  bite,  the  latter 
should  be  shoved  forward  against  it  by  a pencil,  or  little  stick  running 
through  the  tube ; the  tube  may  also  be  employed  to  bring  the  mouth 
of  the  leech  in  contact  with  any  part  of  the  buccal  or  nasal  mucous 
membranes. 

When  the  leeches  are  gorged,  they  will  generally  relax  their  hold 
and  drop  off,  though  should  it  be  necessary  to  arrest  their  action  at 
an  earlier  period  than  that,  a little  salt,  snuff,  or  ashes,  may  be  sprinkled 
upon  them  ; no  tractile  force  should  be  exercised  for  this  purpose,  as 
it  is  calculated  to  damage  the  jaws  of  the  leech,  and  leave  a portion 
of  the  suctorial  apparatus  sticking  in  the  skin. 

It  has  been  proposed,  in  order  to  increase  the  rapacity  of  the  leech 
for  drawing  blood,  to  clip  off  the  point  of  his  tail,  after  he  is  gorged. 
The  operation  is  rarely  successful,  and  always  fatal  to  the  animal; 
besides,  after  the  leech  falls  off'  the  bleeding  may  be  continued  by  the 
application  of  warm  water-dressings,  poultices,  or  a cupping-glass,  so 
that  really  there  is  no  necessity  for  this  barbarous  treatment. 

In  some  instances  the  hemorrhage  continues  after  the  leech-bites 
have  been  exposed  to  the  air  without  any  of  these  warm  applications, 
and  to  such  an  extent  as  to  call  for  the  interference  of  the  surgeon. 
Generally,  the  compression  exercised  upon  the  wounds  by  a little  cone 
formed  by  twisting  a piece  of  lint  or  charpie,  and  a roller  bandage, 
will  suffice  to  stop  the  bleeding.  Another  efficient  remedy  is  the  in- 
troduction of  the  fine  point  of  a stick  of  nitrate  of  silver  into  the 
bite;  others  have  found  it  necessary  to  employ  the  actual  cautery  or 
the  twisted  suture,  before  the  hemorrhage  could  be  arrested ; such  cases 
must  be  rare,  and  mostly  occur  in  persons  of  the  hemorrhagic  diathesis. 

Saturated  solutions  of  alum,  of  sulphate  of  zinc,  the  liquor  of  the 
persulphate  of  iron,  and  other  astringents,  are  also  efficient  applica- 
tions, and  may  be  used  upon  pledgets  of  lint  thrust  into  the  wound 
with  a needle,  and  supported  with  a compress  and  roller. 

Accidents  have  happened  from  the  leeches  getting  into  the  stomach 
and  rectum,  as  in  the  cases  observed  by  Baron  Larrey,  where  they 
were  swallowed  with  the  water  that  soldiers  drank  from  the  pools  in 
Egypt.  They  have  also  been  known  to  detach  themselves  from  the 
nasal  and  buccal  mucous  membranes,  and  escape  into  the  stomach. 
The  remedy  in  these  cases  is  the  prompt  administration  of  salt  water 
or  vinegar  in  the  form  of  a drink,  or  as  an  injection  if  the  animals 
have  crawled  into  the  rectum. 

Wounds  of  the  temporal  artery  and  external  jugular  vein  have 
been  seen  to  result  from  leech-bites ; compression  will  succeed  in 
arresting  the  hemorrhage  from  those  vessels. 

The  classes  of  cases  in  which  leeching  is  employed,  are  in  the  treat- 
ment of  the  inflammatory  diseases  of  infants  where  abstraction  of 
blood  is  indicated,  and  in  whom  general  bleeding  cannot  be  performed 
with  safety ; and  in  the  local  inflammations  of  the  various  organs  of 
the  body,  in  which  leeching  is  both  depletive  and  counter-irritant.  In 


LOCAL  BLEEDING. 


613 


Fig.  563. 


phlegmonous  erysipelas  it  has  been  advised  to  abstain  from  the  use 
of  leeches,  upon  the  supposition  that  their  bites  would  add  to  the 
severity  of  the  malady ; but  the  objection  does  not  appear  to  be  sus- 
tained by  actual  observation. 

The  arrangement  and  care  of  leeches  is  an  important  matter,  and 
deserve  a moment’s  consideration.  After  the  animals  have  been  once 
applied,  the  blood  may  be  removed  from  their  stomachs  by  throwing 
them  into  a solution  of  common  salt,  sixteen  parts  to  a hundred  parts 
of  water ; then  remove  them  one  by  one,  and  holding  the  animal  by  the 
tail  in  water  that  feels  hot  to  the  hand,  draw  him  gently  through  the 
fingers  to  expel  the  blood.  After  this  treatment  they  should  be  placed 
dn  clean,  fresh  water,  which  must  be  changed  once  a day  ; on  the  eighth 
day,  they  may  again  be  used  when  required. 

Leeches  are  liable  to  epidemic  diseases,  which  destroy  them  rapidly; 
and  the  best  means  to  preserve  them  from  these,  as  well  as  to  sustain 
them  in  vigorous  health,  is  to  place  them  under  those  natural  condi- 
tions, as  near  as  can  be,  in  which  they  are  found.  For 
this  purpose  numerous  methods  have  been  suggested, 
of  which  the  simplest  is,  to  select  a jar  in  which  soft 
clear  water  is  put,  throw  the  leeches  into  this,  and  keep 
the  jar  covered  with  a linen  cloth;  the  water  must  be 
changed  twice  a week  in  winter  and  once  a day  in  sum- 
mer, care  being  taken  that  all  slimy  matter  adhering  to 
the  animals  is  removed. 

In  a state  of  nature  leeches  clean  themselves  of  this 
slimy  material,  upon  the  freedom  from  which  their 
health  so  much  depends,  by  crawling  through  the 
interlacing  mosses  of  the  marshes  in  which  they  live. 

To  furnish  a condition  analogous  to  this,  it  will  be 
advisable  to  put  in  the  bottom  of  the  jar  some  earth, 
or,  better  still,  clumps  of  peat. 

Mechanical  Leeches. — An  effort  has  been  made, 
without  much  success,  however,  to  furnish  an  instrument 
for  local  depletion,  resembling  in  its  action  that  of  the 
leech.  The  figure  (563)  illustrates  the  manner  in  which 
this  instrument  may  be  made. 

It  consists  of  a suction-tube  (E)  and  an  air-pump  (A) 
connected  by  the  screw  B ; C is  a rod  working  air- 
tight through  the  cap  of  the  suction-tube,  and  armed 
at  its  lower  extremity  with  three  sharp  points  (D)  to  puncture  the 
skin. 


Kolbe’s  mechani- 
cal leech. 


614 


EXTRACTION  OF  THE  TEETH. 


CHAPTEE  XII. 

EXTRACTION  OF  THE  TEETH. 

The  extraction  of  the  teeth  claims  a place  in  a treatise  of  this 
character,  as  it  is  an  elementary  operation  for  the  performance  of 
which  country  practitioners  and  the  medical  officers  of  the  army  and 
navy  are  often  called  upon.  In  cities,  a special  class  of  persons  are 
commonly  charged  with  this  duty,  \tfho  by  continual  practice  acquire 
sufficient  manual  dexterity  to  save  the  patient  a good  deal  of  suffering, 
and  also,  perhaps,  from  accidents  of  a serious  character  which  have 
often  happened  at  the  hands  of  ignorant  persons. 

The  extraction  of  a tooth,  though  so  simple  in  appearance,  requires, 
nevertheless,  some  surgical  knowledge  and  dexterity  for  its  correct 
performance ; for  an  unskilful  hand  has  produced  fracture  of  the 
alveolus  and  antrum  maxillare,  wounds  of  the  gums,  and  in  some 
cases,  serious  nervous  disturbance  in  delicate  females;  hence,  every 
surgeon,  who  may  be  liable  to  be  called  upon  to  perform  this  operation, 
should  at  least  familiarize  himself  with  the  proper  method  of  accom- 
plishing it. 

From  the  manifest  inadaptability  of  the  " Key  of  Garengeot”  to  the 
extraction  of  the  incisor  teeth,  the  forceps  have  always  been  used  for 
this  purpose;  and  since  1830  so  many  improvements  have  been  made 
in  their  construction,  that  now  operators  almost  exclusively  employ 
them  upon  the  molars  as  well. 

Forceps  require  more  skill  in  their  use  than  the  “key,”  but  they 
are  at  the  same  time  a safer  instrument,  inasmuch  as  the  power  exerted 
upon  the  tooth  is  mostly  parallel  with  its  length,  or  the  direction  it 
takes  in  being  dislodged,  while  the  action  of  the  key  is  exactly  the 
reverse. 

For  the  proper  performance  of  the  operation,  at  least  seven  pairs  of 
forceps  are  required.  One  pair  for  the  upper  incisors  and  cuspidati; 
which,  as  seen  in  Fig.  564,  have  straight  grooved  jaws  sufficiently  thin 


Fig.  564. 


Forceps  for  the  upper  iacisors  and  cuspidati. 


at  their  points  to  be  introduced  between  the  gum  and  neck  of  the 
tooth ; the  handles  should  be  strong  enough  not  to  spring  in  the  hand 


EXTRACTION  OF  THE  TEETH. 


615 


when  firmly  grasped ; the  extremity  of  one  of  them  is  turned  up  so 
as  to  prevent  the  hand  slipping  by  hooking  around  its  ulnar  border. 

The  necks  of  the  lower  incisors  being  narrow,  the  forceps  intended 
for  them  should  have  very  narrow  points,  and  the  jaws  curved  below 


Fig.  565, 


Forceps  for  the  lower  incisors  and  cuspidati. 


the  articulation  so  as  to  form  an  angle  of  twenty  degrees  with  the 
handles  (Fig.  565). 

For  the  extraction  of  the  bicuspidati  of  both  jaws  the  forceps  seen 
in  Fig.  566  are  well  adapted ; their  points  are  broadly  grooved,  so  as 
to  take  a good  hold  of  the  tooth. 


Fig.  566. 


Forceps  for  the  bicuspidati. 


For  the  lower  molars  but  one  pair  of  forceps  will  be  required ; they 
should  be  strong,  and  curved  at  the  beak  in  front  of  the  articulation ; 
each  point  has  two  grooves,  with  a projecting  tip  between  them,  so 


Fig.  567. 


Forceps  for  the  lower  molars. 


situated  that  in  grasping  the  tooth  the  points  will  lodge  upon  either 
side  of  it  below  the  bifurcation  of  the  roots.  The  handles  may  be 
straight,  as  seen  in  Fig.  567,  or,  what  is  better,  have  one  of  them 
curved  at  its  extremity  so  that  the  hand  may  not  slip. 

From  the  anatomical  arrangement  of  the  roots  of  the  upper  molars 
two  pairs  of  forceps  will  be  necessary,  one  pair  for  those  upon  the 
right  side,  and  the  other  for  those  upon  the  left.  Their  jaws  are  curved 
in  front  of  the  articulation,  and  the  handles  behind  it ; it  will  be 
seen  in  the  annexed  wood-cuts,  Figs.  568,  569,  that  that  point  which 
is  to  be  applied  to  the  palatine  face  of  the  neck  of  the  tooth  is  simply 
concave,  while  the  opposite  one  is  both  grooved  and  pointed  to  catch 
between  the  bifurcation  of  the  roots  upon  its  external  side. 


616 


EXTRACTION  OF  THE  TEETH. 


Fig.  568. 


Forceps  for  the  right  upper  molars. 


Fig.  569. 


Forceps  for  the  left  upper  molars. 


From  the  position  of  the  dentes  sapientise  far  back  in  the  mouth  a 
peculiarly  constructed  instrument  is  called  for,  such  as  is  shown  in  Fig. 
570;  the  jaws  resemble  in  form  the  letter  Z,  aud  enable  the  surgeon  to 


Fig.  570. 


Forceps  for  the  last  molars. 


get  a firm  grasp  upon  these  teeth,  without  being  interfered  with  by 
the  teeth  of  the  lower  jaw. 

For  the  purpose  of  removing  the  roots  of  the  teeth  the  narrow 
pointed  forceps  above  described  will  answer  very  well,  though  con- 
siderable assistance  may  be  derived  from  the  screw  and  elevator,  the 
forms  of  which  are  so  well  known  as  not  to  require  any  special  descrip- 
tion in  this  place. 

In  applying  the  forceps  the  points  of  their  jaws  must  be  shoved 
well  in  between  the  gums  and  neck  of  the  tooth,  and  just  sufficient 
amount  of  pressure  made  upon  the  handles  to  insure  the  instrument 
from  slipping;  then,  if  it  is  a front  tooth  that  is  being  extracted 
(Fig.  571),  move  the  forceps  backwards  and  forwards  two  or  three 
times;  give  them  a little  rotatory  movement,  and  lift  the  tooth  up- 
wards from  its  socket.  In  extracting  the  molars  the  forceps  must  be 
moved  laterally  to  loosen  the  tooth,  and  the  force  then  applied  in  a 
perpendicular  direction  with  its  axis. 


EXTRACTION  OP  THE  TEETH. 


617 


Some  have  deemed  the  preliminary  use  of  a lancet  necessary  in 
separating  the  gums  from  the  teeth  ; but  this  is  not  at  all  required  if 
the  jaws  of  the  forceps  are  well  forced  up  around  the  neck  of  the  tooth 
(Fig.  572). 

The  instrument  sometimes  employed  in  Flg-  s?1- 

extracting  teeth  called  the  “key”  was  in- 
vented by  Grarengeot : and  since  his  time  it 
has  undergone  various  modifications,  both 
in  the  shape  of  the  stem,  and  in  that  of  the 
fulcrum. 

The  “key-bit”  should  be  of  sufficient  width 
to  be  placed  upon  the  gums  at  an  advanta- 
geous distance  from  the  tooth  to  be  extract- 
ed. If  too  near  this,  the  crown  of  the  tooth 
will  be  broken  ; if  too  far,  the  alveolus  will 

Fig.  572. 


Forceps  in  extracting  upper  molars. 


Forceps  in  extracting  lower  incisor. 


suffer  a similar  fate.  To  the  “ bit”  the  hook  is  to  be  secured  with 
a pin  provided  with  a thread,  so  that  the  former  cannot  become 
detached  from  the  fulcrum.  The  hook  is  curved,  and  terminates 
at  its  point  in  an  edge  about  one-sixteenth  of  an  inch  in  width,  with 
a little  notch  at  its  centre  dividing  the  edge  into  two  little  points, 
which  are  intended  to  prevent  the  instrument  slipping  from  the  tooth. 
The  stem  of  the  key  is  curved  where  it  joins  with  the  fulcrum,  so 
that  it  may  not  be  interfered  with  by  the  front  teeth  when  we  are  ope- 
rating upon  the  molar.  The  handle  is  fitted  crosswise  the  stem,  and 
secured  to  the  latter  by  a milled-head  screw,  removable  at  pleasure, 
so  as  to  make  the  instrument  more  portable,  and  if  there  is  need,  per- 
mit the  handle  to  be  used  in  connection  with  the  stem  of  any  other 
instrument. 

By  withdrawing  the  pin  from  the  “ key-bit”  the  hook  may  be  de- 
tached and  changed  to  either  side  of  the  fulcrum,  as  the  necessities  of 
the  case  require.  Two  or  three  hooks  of  different  sizes  should  always 
accompany  the  instrument,  adapted  to  the  varying  dimensions  of  the 
tooth. 

In  operating  with  the  key,  we  select  a hook  of  the  proper  size,  and 
fasten  it  to  the  fulcrum,  taking  care  to  envelop  the  latter  with  a piece 
of  bandage  or  the  end  of  a napkin,  so  that  the  gums  may  not  be 
wounded  by  its  pressure. 

The  handle  of  the  instrument  is  held  in  the  right  hand,  while  with 
the  index  finger  of  the  left  we  guide  the  hook  to  the  tooth  we  wish 
to  remove,  and  force  its  edge  between  the  gum  and  inner  surface  of 
its  neck  near  the  edge  of  the  alveolus,  as  seen  in  Fig.  573 ; then  by 
a gentle  twisting  movement  the  tooth  is  made  to  move  towards  the 


618 


CAT  II  ETERIS  51. 


Mode  of  using  the 
key  in  extracting 
teeth. 


fulcrum,  and  at  the  same  time  upwards ; when  com- 
pletely loosened  in  this  manner,  by  elevating  the  key 
the  tooth  is  removed. 

As  a general  rule  the  fulcrum  is  placed  upon  the 
outside  of  the  gum ; though  should  the  tooth  have  a 
decided  curve  towards  the  tongue,  or  have  its  inner 
wall  destroyed  by  caries,  the  fulcrum  may  be  estab- 
lished upon  the  inner  side  of  the  dental  arch. 

Extreme  pain  is  almost  always  caused  by  the  extrac- 
tion of  teeth,  whether  performed  with  the  forceps  or  the 
key,  which  usually  disappears  in  a short  period,  but 
may  last  for  several  days.  Fractures  of  the  alveolus 
sometimes  occur ; if  the  fragment  is  small,  it  will  gene- 
rally escape  after  the  lapse  of  a few  days ; a large  piece 
of  bone  should  be  supported  in  its  natural  position,  and  it  will  soon 
become  reunited  to  the  jaw.  By  a bungling  operator,  the  teeth 
adjacent  to  the  one  he  wishes  to  remove  may  be  loosened,  or  even 
broken. 

It  rarely  happens  that  there  is  much  bleeding  after  extraction, 
though  cases  are  recorded  in  which  the  hemorrhage  was  obstinate ; 
should  such  an  instance  be  encountered,  a good  plan  to  pursue  is  as 
follows:  Soak  a small  ball  of  cotton  or  charpie  in  the  tincture  of  the 
perchloride  of  iron,  and  press  it  into  the  tooth  socket  firmly ; over 
this  place  other  pieces  of  the  same  material  until  the  alveolus  is  quite 
full,  and  the  plug  projects  above  the  crowns  of  the  two  adjacent  teeth ; 
then  mould  a piece  of  sheet  lead  over  the  plug,  and  after  bringing  the 
jaws  firmly  together,  sustain  them  in  this  position  by  one  of  the 
bandages  for  the  head  and  jaw  already  described. 

Some  persons  have  found  it  necessary  to  cauterize  the  alveolar 
cavity  with  the  point  of  a hot  wire. 


CHAPTER  XIII. 

CATHETERISM. 

Catheterism  is  the  introduction  of  the  catheter,  sound,  or  bougie 
into  any  of  the  natural  passages  of  the  body,  such  as  the  urethra, 
Eustachian  tube,  or  the  nasal  duct.  When  the  word  is  used  without  a 
qualifying  adjective,  it  simply  defines  the  operation  as  performed  upon 
the  urethra. 

Various  instruments  are  used  in  executing;  this  ooeration,  according 
to  the  position  and  anatomical  structure  of  the  canal ; though  the 
results  obtained  in  different  cases  are  often  identical:  thus,  the 
catheter  may  be  introduced  into  the  bladder  and  stomach  for  the 
purpose  of  removing  their  contents ; or,  again,  with  the  view  of  over- 
coming a constriction  or  narrowing  in  the  urethra  or  oesophagus.  It 


CATHE’TERISM  OF  THE  NASAL  DUCT. 


Fig.  574. 


619 


Diagram  showing  the  anatomical  rela- 
tions of  the  canalicnli  with  the  nasal  duct : 
2,  puncta ; 3,  3,  canaliculi  terminating  by 
a common  trunk  (4)  into  the  lachrymal 
sac  (5). 


becomes  necessary  sometimes  to  inject 
fluid  substances  into  the  Eustachian 
tube,  nasal  duct,  trachea,  and  bladder. 

Important  information  is,  likewise, 
obtained  by  this  operation,  of  the  con- 
dition of  the  walls  of  these  passages;  it 
declares  the  presence  or  absence  in  them 
of  foreign  matters,  as  well  as  morbid 
alteration  in  their  caliber.  Introduced 
into  the  bladder,  the  sound  serves  as  a 
guide  for  the  knife  in  lithotomy ; and 
with  a peculiarly  constructed  catheter 
the  surgeon  is  enabled  to  plug  the  nares 
so  as  to  arrest  profuse  hemorrhage. 

Catheterism  of  the  Nasal  Duct. — 

The  nasal  duct,  lodged  in  the  lachry- 
mal canal,  commences  at  the  inner 
canthus  of  the  eye  in  a slight  enlarge- 
ment, the  lachrymal  sac,  into  which  the 
canaliculi  empty — sometimes  separately, 

but  in  almost  all  cases  by  one  orifice,  as  seen  in  Fig.  574 — Fig-  575 
and  terminates  in  the  inferior  meatus  of  the  nose  in  a slightly 
expanded  orifice  near  its  floor,  and  about  six  lines  from  the 
orifice  of  the  nostril;  it  is  about  one-half  inch  in  length  and 
two  lines  in  diameter,  and  slightly  curved  upon  itself,  the 
convexity  being  outwards ; the  canaliculi  are  about  one  line 
wide  and  three  lines  long,  commencing  upon  the  inner  mar- 
gin of  the  tarsal  cartilages,  the  superior  taking  a direction 
upwards  and  inwards,  the  inferior  downwards  and  inwards. 

The  operation  may  be  performed  through  the  puncta, 
through  an  incision  at  the  inner  canthus  into  the  lachrymal 
sac,  or  through  the  inferior,  orifice  of  the  duct,  its  object 
being  in  each  case  to  dilate  the  nasal  duct,  and  thus  to  restore 
the  natural  flow  of  the  tears  through  it. 

In  the  first  instance,  the  operation  is  performed  with  deli- 
cate flexible  probes  of  silver,  invented  by  the  French  sur- 
geon Anel.  It  is  accomplished  in  the  following  manner : 

To  dilate  the  upper  canaliculus,  the  tarsal  cartilage  is  seized 
between  the  thumb  and  index  finger,  and  slightly  drawn 
out;  the  probe  is  held  in  the  right  hand  like  a pen,  with  its 
point  in  the  superior  puncture,  and  pressed  gently  upwards 
about  two  lines,  when  the  probe  is  brought  parallel  with  the 
ciliary  border  of  the  upper  eyelid;  shoved  inwards  a little; 
then  gradually  raised  vertically  in  a line  with  the  supra- 
orbital notch,  and  pressed  inwards  and  downwards  into  the 
lachrymal  sac.  The  duct  may  be  entered  through  the  lower 
canaliculus  by  passing  the  point  of  the  probe  downwards 
about  one-tenth  of  an  inch  into  the  inferior  puncture,  then 
inwards  and  slightly  upwards. 

When  the  nasal  duct  is  to  be  dilated  through  an  artificial  Aael’s  Probe- 


620 


CATHETER ISM. 


orifice,  catguts  and  styles  are  employed,  such  as  are  seen  in  Figs.  576, 
577,  578.  The  styles  are  made  of  silver  or  lead,  and  the  sizes  used  are 

Fig.  576.  Fig.  577.  Fig.  576. 


Styles  for  dilating  nasal  duct. 

to  be  gradually  increased  from  the  smallest  to  the  largest,  as  the  duct 
yields.  Fig.  578  shows  a style  that  may  be  extemporized  at  any  moment 
from  a piece  of  lead-wire  six  to  eight  lines  long,  of  the  proper  dimen- 
sions, rounded  at  one  end  and  bent  at  the  other. 

Fig.  579. 


The  instrument  for  dilating  the  duct  from  below  is  seen  in  Fig.  579. 
It  is  to  be  introduced  in  the  manner  we  have  already  described  at 
page  107,  for  the  catheter  of  Gensoul. 

Catheterism  of  the  Eustachian  Tube. — Catheterism  of  the 
Eustachian  tube  is  now  performed  as  a diagnostic  means,  and  for  the 


Fig.  580. 


introduction  of  air  into  the  cavity  of  the  tympanum.  For  the  latter 
purpose,  the  instrument  seen  in  Fig.  580  is  employed. 


PLUGGING  THE  POSTERIOR  NAEES. 


621 


The  catheter  is  introduced  by  holding  it  lightly  between  the  thumb, 
middle,  and  index  fingers,  and  passing  its  point  backwards  along  the 
floor  of  the  nares,  with  the  convexity  upwards.  When  about  four 
inches  deep,  and  the  point  has  reached  the  veil  of  the  palate,  indi- 
cated by  the  acts  of  deglutition  which  it  excites  when  it  arrives  at 
that  place,  the  extremity  of  the  catheter  should  be  rotated  against  the 
outer  wall  of  the  pharynx  to  enter  the  orifice  of  the  Eustachian  tube, 
which  is  situated  about  eight  lines  above  the  plane  of  the  floor  of  the 
nares.  To  assure  himself  that  the  beak  of  the  instrument  is  in  the 
orifice  of  the  tube,  the  surgeon  should  gently  pull  the  catheter  for- 
wards, when  a feeling  of  resistance  will  be  perceived  if  the  operation 
is  successful.  The  point  of  the  elastic  tube  is  now  fixed  to  the  cathe- 
ter, which  is  to  be  sustained  in  the  left  hand,  while  the  surgeon  takes 
the  other  end  of  the  tube  in  his  mouth,  and  gently  forces  air  into  the 
cavity  of  the  tympanum. 

This  operation  is  performed  in  certain  cases  of  deafness  for  the  pur- 
pose of  removing  mucus  from  the  Eustachian  tube,  and  liberating  the 
lips  of  its  faucial  orifice  after  appropriate  remedies  have  been  employed 
to  diminish  the  hypertrophy  of  the  mucous  membrane  lining  it. 

Plugging  the  Posterior  Nares. — Plugging  of  the  posterior 
nares  is  a species  of  catheterism  which  we  sometimes  have  recourse 
to,  to  control  hemorrhage  from  the  nasal  fossm,  when  either  by  its 
quantity  or  duration  it  becomes  threatening,  and  after  other  simpler 
means  have  failed. 

The  operation  is  usually  performed  with  a special  instrument  called 
the  “sound  of  Belloc.”  It  consists  of  a silver  tube  about  seven  inches 
long,  curved  at  one  of  its  extremities;  the  other  extremity  has  a ring 
soldered  to  it  corresponding  with  the  side  of  the  curve,  which  enables 
the  operator  to  judge  exactly  where  the  point  of  the  instrument  is 
after  it  is  introduced ; through  the  tube  a steel  spring  runs  for  half 


Fig.  581. 


J 


Belloc’s  sound, 

its  length,  having  an  eyed  point,  and  fastened  at  the  other  end  to  a 
metallic  stem  (b),  by  means  of  which  it  may  either  be  projected  from 
or  withdrawn  into  the  tube. 

When  this  instrument  is  not  at  hand,  an  ordinary  gum  catheter  can 
be  used  in  the  following  manner : Take  a doubled  thread,  and  tie  its 
loop  or  bight  to  the  point  of  the  catheter,  which  should  be  furnished 
with  a wire  stylet,  so  that  it  may  maintain  the  curved  form  impressed 
upon  it ; then,  holding  the  catheter  with  the  free  ends  of  the  threads 
in  the  right  hand,  pass  its  beak  along  the  floor  of  the  nares,  with  its 


622 


CATHETER ISM. 


point  downwards,  until  it  reaches  the  pharynx,  when  the  stylet  should 
be  withdrawn  a little,  and  the  patient  then  directed  to  breathe  forcibly; 
the  point  will  then  come  sufficiently  forwards  to  be  grasped  in  a pair 
of  forceps  and  drawn  into  the  mouth ; the  thread  should  now  be 
loosened  from  the  catheter,  and  the  latter  withdrawn,  when  a plug  of 
the  proper  dimensions,  having  a single  thread  attached  to  it,  may  be 
fastened  in  the  loop  of  the  doubled  thread.  A simple  thread  rolled  into 
a little  ball  and  placed  in  the  nostrils  will  be  drawn  into  the  pharynx 
by  directing  the  patient  to  make  short  and  quick  inspiratory  actions 
with  the  mouth  closed ; the  end  of  the  thread  may  then  be  seized  and 
drawn  into  the  mouth. 

Another  expedient  is  to  join  a little  sac  of  thin  bladder  or  gold- 
beater’s skin  to  the  point  of  a catheter,  and  thrust  this  into  the  posterior 
nares,  after  which  it  may  be  distended  with  air  or  water.  Similar  to 
this  is  the  instrument  of  M.  Gariel,  consisting  of  a gum-elastic  tube 
capable  of  being  dilated  at  one  extremity  into  a size  sufficient  to  fill 
up  the  posterior  nares,  and  furnished  at  the  other  with  a stopcock. 
After  it  is  introduced  into  the  nose,  the  tube  is  dilated  either  with  air 
or  water. 

In  using  the  instrument  of  Belloc,  two  compresses  are  to  be  made 
from  patent  lint  or  other  suitable  material,  and  of  convenient  size,  one 
for  the  posterior  nares,  and  the  other  for  the  orifice  of  the  nose ; to 
the  centre  of  the  former  a double  thread  is  attached,  intended  to  be 
drawn  through  the  nares,  and  also  a single  thread,  destined  to  hang 
from  the  mouth,  and  by  which  the  compress  is  withdrawn.  Thus 
prepared,  the  surgeon  now  passes  the  “sound”  through  the  nostril  into 
the  pharynx,  and  then  thrusts  the  spring  forwards  by  the  metallic 
stem,  which,  from  its  curved  form,  enters  the  mouth  from  behind,  and 


Fig.  5S2. 


may  be  seized  with  the  fingers  and  held  while  the  double  thread  is 
being  passed  through  its  eyed  point ; after  this  is  done,  the  spring  is 
drawn  into  the  canula,  and  the  instrument  removed,  bringing  along 


CATHETER1SM  OF  THE  (ESOPHAGUS. 


623 


with  it  the  double  thread,  which  must  be  held  in  the  left  hand,  and 
gentle  traction  made  upon  it,  while  the  surgeon  with  his  right  index- 
finger  guides  the  compress  through  the  mouth  and  up  behind  the  soft 
palate,  leaving  the  single  thread  hanging  from  the  mouth.  The  second 
compress  is  now  placed  over  the  meatus  of  the  nose,  and  the  double 
thread  tied  upon  it.  In  this  manner  the  hemorrhage  is  arrested ; for 
the  nares,  being  plugged  anteriorly  and  posteriorly,  become  filled  with 
blood,  and  pressure  is  thereby  brought  to  bear  upon  the  bleeding 
vessels.  At  the  end  of  forty-eight  hours  the  flow  of  blood  will  have 
been  checked,  and  the  plug  may  be  removed  by  untying  the  thread 
over  the  anterior  compress,  and  drawing  upon  that  one  in  the  mouth. 

M.  Bretonneau  prefers  the  kite-tail  plug  to  all  other  means  of  plug- 
ging in  epistaxis.  It  is  formed  of  a thread  about  forty  feet  long, 
to  which,  at  intervals  of  about  six  or  seven 
inches,  pieces  of  carded  cotton  (to  be  oiled 
before  using  the  plug)  are  attached. 

Catheterism  of  the  (Esophagus. — Cathe- 
terism  of  the  oesophagus  becomes  necessary 
under  two  conditions:  first,  when  there  is  stric- 
ture ; second,  when  we  wish  either  to  evacuate 
the  contents  of  the  stomach,  or  to  introduce 
into  it  liquid  aliments. 

In  the  first  case  we  use  bougies  made  of 
lead,  silver,  or  gutta-percha.  M.  Boyer  em- 
ployed silver  sounds  successfully.  These  in- 
struments should  be  of  different  sizes,  properly 
curved,  and  of  sufficient  length  to  reach  be- 
yond the  stricture  (Fig.  583). 

To  remove  the  contents  of  the  stomach,  or 
to  inject  nutrient  fluids  into  it,  a long  flexible 
tube  is  employed,  made  of  India-rubber  or 
waxed  cloth  ; one  of  its  ends  is  furnished  with 
a well  rounded  and  fenestrated  tip  of  gutta- 
percha, the  other  is  connected  with  a small 
metallic  force-pump ; the  punlp  itself  is  con- 
structed with  ball-valves,  which  are  the  most  t 

j . j ,,  7 D most  ordinary  position,  with  a 

durable  kind  and  least  likely  to  get  out  of  bougieintroducedbythemouth. 
order,  and  has  also  attached  to  the  side  of  its 

barrel  a second  tube  of  the  same  material  as  the  first.  In  using  the 
instrument,  the  oesophageal  tube  may  be  introduced  into  the  stomach 
either  through  the  nostrils  or  mouth. 

To  pass  the  tube  through  the  nose,  the  larger  meatus,  if  there  is  any 
difference  in  their  size,  should  be  selected ; the  patient  is  seated  in  a 
chair,  or  may  lie  upon  his  back,  and  is  directed  to  extend  the  head  in 
order  to  diminish  the  angle  formed  by  the  nares  and  the  pharynx; 
then  the  tube,  held  in  the  right  hand,  is  carried  along  the  floor  of  the 
nose,  keeping  it  well  against  the  septum,  to  prevent  its  point  catching 
against  the  turbinated  bones ; when  it  has  reached  the  pharynx  the 
patient  must  open  his  mouth  widely  to  enable  the  operator  to  press  the 
end  of  the  tube  with  his  index  finger  towards  the  left  side  that  it  may 
go  more  directly  into  the  superior  orifice  of  the  oesophagus,  the  open- 


Fig.  583. 


624 


CATHETER ISM. 


ing  of  the  larynx  being  nearer  the  median  line.  The  instrument  must 
now  be  passed  slowly  and  gently  into  the  stomach,  wrhich  will  be 
known  by  its  being  suddenly  arrested  by  the  pressure  of  the  point 
upon  the  walls  of  that  viscus. 

The  operation  is  but  little  difficult  to  execute,  and  with  patience 
may  be  readily  accomplished  when  the  tube  may  be  kept  in  the 
stomach  as  long  a period  as  is  required  for  the  attainment  of  the  object 
in  view  by  fastening  it  with  threads,  after  the  manner  of  a catheter, 
to  a T bandage  of  the  nose. 

If  there  is  choice  left,  the  mouth  should  always  be  selected  for  the 
introduction  of  the  tube,  inasmuch  as  this  cavity,  besides  being  more 
capacious,  by  simply  throwing  back  the  head,  may  have  its  axis 
brought  in  a line  with  that  of  the  oesophagus.  With  the  head  in  this 
position,  the  surgeon  depresses  the  tongue  with  his  left  index  finger, 
and  holding  the  tube  in  the  right  hand  he  passes  it  into  the  throat ; the 
irritation  of  the  point  of  the  instrument  will  at  first  cause  the  patient 
to  retch,  or  even  vomit ; but  the  parts,  in  a brief  period,  become  accus- 
tomed to  its  presence,  and  it  may  be  pressed  gently  onwards  to  the 
stomach,  avoiding  the  superior  orifice  of  the  larynx,  and  taking  care 
not  to  perforate  the  walls  of  the  oesophagus,  which  might  happen  should 
they  have  undergone  softening  from  carcinomatous  or  other  morbid 
conditions. 

The  tube  may  be  kept  in  for  some  time,  but  it  is  more  embarrassing 
to  the  patient  than  when  introduced  by  the  nose. 

If  the  object  is  to  evacuate  poison  from  the  stomach,  the  pump  is 
now  attached  to  the  tube,  and  a quantity  of  water  injected : this  is  re- 
moved, and  more  fresh  water  introduced ; and  this  in  turn  pumped  out;  , i 
until  by  the  repetition  of  the  process  the  fluid  removed  is  perfectly 
clean  and  clear,  taking  care  never  to  empty  the  stomach  entirely,  as 
there  is  a risk  of  the  mucous  lining  of  the  organ  being  damaged.  In 
injecting  fluids  into  the  stomach  the  operator  should  be  certain  that 
the  tube  is  in  that  viscus,  for  it  has  happened  in  several  cases  that  in- 
stead of  putting  it  into  the  stomach  the  lungs  have  been  flooded,  in  one 
instance  upon  record  with  chalk  mixture,  and  in  another  with  soup. 
This  is  more  likely  to  happen  if  the  patient,  during  the  operation,  is 
insensible. 

To  prevent  the  tube  being  bitten,  a wooden  gag  with  a hole  through 
it  may  be  introduced  between  the  teeth. 

Catheterism  of  the  Larynx  and  Trachea. — Dr.  Horace  Green, 
of  Hew  York,  has  established  both  the  practicability  and  the  utility 
of  catheterization  of  the  larynx. 


Fig.  584. 


Sponge  nrobang. 


He  employs  the  instrument  seen  in  Fig.  584,  consisting  of  a stout 
whalebone  handle  about  ten  inches  long  and  bent  at  its  extremity,  which 


CATHETERISM  OF  THE  URETHRA. 


625 


is  mounted  with  a pellet  of  soft  sponge,  at  an  angle  of  nearly  45°.  The 
operation  is  performed  by  seating  the  patient  in  a chair  with  his  head 
thrown  back  and  the  mouth  as  widely  open  as  possible ; the  surgeon 
presses  the  tongue  down  with  a depressor,  and  holding  the  probang 
in  his  right  hand,  glides  the  sponge  towards  the  epiglottis,  at  the 
same  time  directing  the  patient  to  take  a deep  inspiration,  when  the 
point  of  the  instrument  is  slipped  into  the  larynx.  It  needs  to  rest 
there  but  a single  moment,  and  should  be  quickly  withdrawn.  The 
cases  in  which  the  operation  has  been  performed  are  syphilitic  and 
tubercular  ulceration  of  the  larynx,  excrescences  about  the  vocal  cords, 
and  oedema  of  the  glottis.  The  application  usually  made  use  of  is  a 
solution  of  the  prystallized  nitrate  of  silver  in  water,  of  the  strength 
of  forty  to  sixty  grains  of  the  former  to  an  ounce  of  the  latter. 

In  the  hands  of  Dr.  Horace  Green  the  probang  has  been  carried 
into  the  trachea,  and  even  as  far  as  the  bronchi. 

Catheterism  OF  the  Large  Intestines. — Catheterism  of  the  large 
intestines  is  employed  to  relieve  flatulent  distension  of  the  colon,  and 
in  stricture  of  the  rectum. 

In  the  first  instance  the  long  flexible  tube  of  the  stomach-pump  will 
answer  very  well;  it  should  be  well  oiled,  and  gently  pushed  into  the 
rectum  to  as  high  a point  as  is  requisite  to  remove  the  accumulated 
gas.  I have  on  several  occasions  introduced  this  instrument  to  a 
distance  of  two  feet  into  the  bowel  without  any  difficulty,  and  in  very 
thin  persons  it  may  be  felt  in  the  transverse  colon ; if  cold  water  is 
thrown  in  the  patient  first  experiences  its  impression  at  that  point  of 
the  colon  corresponding  with  the  point  of  the  tube ; showing  clearly 
that  the  tube  has  not  been  doubled  upon  itself. 

In  the  treatment  of  stricture  of  the  rectum  bougies  of  India-rubber, 
metal,  wax,  or  wax-cloth  are  used ; also  several  special  kinds  of  dila- 
tors. 

Their  introduction  should  be  accomplished  with  the  greatest  care, 
the  smallest  instrument  being  first  employed  that  will  pass  the  stric- 
ture, the  size  being  insensibly  increased  as  the  constriction  yields. 

To  overcome  some  of  the  objections  to  the  bougie  special  dilators 
have  been  invented,  which,  when  closed,  form  a slender  stem  that  may 
easily  pass  the  stricture,  and  then  can  be  enlarged  to  any  dimension 
by  turning  a screw  placed  upon  the  handle  for  that  purpose. 

In  others  constructed  of  India-rubber  the  dilatation  is  effected  by  the 
insufflation  of  air  into  their  cavities. 

Catheterism  of  the  Uterus. — Sometimes,  from  the  narrowing  or 
closure  of  the  os  uteri,  catheterism  becomes  necessary,  and  may  be 
effected  with  bougies  made  of  metal,  India-rubber,  or  waxed  cloth; 
they  should  be  of  different  sizes,  and  their  introduction  into  the  os 
effected  with  the  greatest  gentleness.  The  smallest  size  should  be  used 
at  first,  and  permitted  to  remain  two  or  three  hours  each  time  for  a 
few  days  until  the  parts  become  accustomed  to  the  presence  of  the 
instrument,  after  which  other  sizes  are  employed  until  the  requisite 
amount  of  dilatation  is  effected.  Special  dilators  have  also  been  in- 
vented for  the  same  purpose. 

Catheterism  of  the  Urethra. — Catheterism  of  the  urethra  is 
40 


626 


CATHETERISM. 


required  to  be  performed  in  retention  of  urine  from  various  causes — 
contraction  of  the  voluntary  or  involuntary  muscular  fibres  surround- 
ing the  urethra,  paralysis  of  the  bladder,  stricture,  etc. 

In  many  cases  other  measures  will  often  succeed  in  relieving  the 
bladder,  such  as  the  immersion  of  the  patient  in  a warm  bath,  the  in- 
halation of  the  anaesthetics,  the  administration  of  a full  dose  of  mor- 
phia or  other  narcotic,  or  an  injection  containing  opium  or  camphor ; 
sometimes  the  evacuation  of  the  rectum  by  a large  enema,  or  the  free 
use  of  alkaline  draughts  will  accomplish  the  same  object : tincture  of 
the  muriate  of  iron  in  ten-drop  doses  every  ten  minutes  is  an  empirical 
remedy  occasionally  had  recourse  to. 

Catheterism  of  the  Male  Urethra. — The  instruments  used  in 
this  operation  are  cylindrical  tubes  made  of  silver,  waxed  cloth  or 
India-rubber  of  different  sizes  and  forms.  The  scale  of  sizes  adopted 
by  some  of  the  instrument  makers  is  shown  in  Fig.  585. 

Fig.  585. 

/ 2 3 k 5 6 JL  JL  JL 

oooooo  O 00 

Diagram  showing  the  sizes  of  catheters. 

The  catheter  should  be  curved  at  its  extremity  to  some  extent, 
although  a perfectly  straight  instrument  may  be  made  to  pass  into  the 
bladder.  The  form  seen  in  Fig.  586  is,  perhaps,  the  best : in  this  the 
axis  of  the  beak  makes  with  that  of  the  shaft  an  angle  little  less  than 

Fig.  586. 


a right  angle ; its  point  is  well  rounded,  and  pierced  a short  distance 
above  with  two  oval  holes  or  “ eyes”  at  different  heights ; to  the  open 
extremity  of  the  tube  two  little  rings  are  soldered  for  the  purpose  of 
attaching  a retentive  bandage  if  required ; and  also  to  serve  as  an 
indication  of  the  position  of  the  point  of  the  instrument. 

Method  of  Introduction. — The  patient  may  stand  in  front  of  the  sur- 
geon, while  the  latter  sits  in  a chair,  or  he  may  lean  with  his  back 
against  a wall,  or  again,  he  may  sit  upon  the  edge  of  the  bed,  with  his 
knees  widely  separated,  and  the  feet  supported  on  a stool ; though  the 
most  convenient  position  both  for  the  surgeon  and  patient  is  for  the 
latter  to  assume  a horizontal  posture,  with  his  shoulders  slightly  ele- 
vated, the  thighs  drawn  up,  and  the  knees  wide  apart.  The  surgeon 
having  warmed,  and  well  oiled  the  catheter,  which  he  holds  lightly  be- 
tween the  thumb  and  index  and  middle  fingers  of  the  right  hand. 


CATHETERISM  OP  THE  MALE  URETHRA. 


627 


stations  himself  upon  the  patient’s  left  side,  as  the  most  convenient  in 
operating ; he  then  takes  the  head  of  the  penis  between  the  fingers  of 
the  left  hand,  makes  pressure  upon  it  to  open  the  meatus,  into  which 
the  point  of  the  instrument,  with  its  concavity  placed  across  the  left 
groin,  is  introduced,  and  pressed  along  the  urethra,  taking  care  to 


Fig.  587. 


Mode  of  introducing  the  catheter. 


keep  the  point  in  contact  with  its  upper  wall  until  it  reaches  the  arch 
of  the  pubis,  when  the  shaft  of  the  instrument  should  be  carried  to 
the  median  line  of  the  abdomen,  and  then  depressed  between  the  thighs, 
which  movement  will  throw  the  point  of  the  catheter  into  the  bladder. 

In  this  manner,  with  a little  practice,  the  catheter  can  be  introduced 
with  neatness  and  rapidity. 

Should  this  method  fail,  there  is  another  plan,  called  by  French 
surgeons  the  “tour  de  maitre,”  which  will  sometimes  succeed;  it  is 
executed  in  the  following  manner : The  patient  may  either  assume 
the  erect  posture  or  lie  down ; the  surgeon  stands  upon  his  right  side, 
and  passes  the  catheter  with  its  open  extremity  looking  downwards, 
into  the  urethra  down  to  the  triangular  ligament ; then  by  a lateral 
sweep  through  a semicircle  he  brings  the  shaft  of  the  instrument  to 
the  median  line  of  the  abdomen;  it  is  now  depressed  towards  the 
thighs,  to  raise  the  point  of  the  catheter  into  the  bladder. 

In  either  case,  it  will  be  known  that  the  instrument  has  entered  the 
bladder  by  the  ceasing  of  the  resistance  to  its  progress,  by  the  flow 
of  urine,  and  by  its  beak  rotating  freely  in  the  bladder  when  the 
shaft  is  rolled  between  the  fingers. 

If  the  silver  catheter  does  not  pass,  a gum  catheter  may  be  tried, 
having  impressed  upon  it  the  curve  deemed  by  the  surgeon  most 
likely  to  insure  its  successful  introduction.  The  wire  stylet  may  be 


628 


CATHETERISM. 


partially  withdrawn  from  the  catheter  in  those  cases  where  the  pros- 
tate gland  is  enlarged,  so  that  its  point  may  rise  above  the  obstruction 
and  enter  the  bladder. 

It  will  be  always  advisable  in  a healthy  urethra  to  use  a large 
instrument  (No.  7 or  8,  for  instance),  as  it  fills  the  canal  fully,  and  is, 
therefore,  less  apt  to  catch  in  the  folds  of  the  mucous  membrane. 
Should  its  point  meet  with  any  obstruction,  the  instrument  may  be 
slightly  withdrawn,  then  again  shoved  forwards ; or  the  penis  may  be 
stretched  by  drawing  it  along  the  shaft  of  the  catheter,  which  will 
sometimes  overcome  the  difficulty. 

In  old  people  the  middle  lobe  of  the  prostate  is  often  so  hyper- 
trophied as  almost  to  close  the 

Fig.  588. 


Hypertrophy  of  the  middle  lobe  of  the  prostate  gland. 


urethra,  as  seen  in  Fig.  588. 
The  open  extremity  of  the 
catheter  in  such  a case  as  this 
must  be  depressed  more  than 
would  be  required  in  operat- 
ing upon  a healthy  urethra,  so 
that  the  point  of  the  iustru-  * 
ment  may  pass  above  the  ob- 
struction ; or  perhaps  a much 
more  effectual  plan  will  be  to 
introduce  into  the  rectum  the 
left  forefinger,  with  which  the 
point  of  the  instrument  may 
be  pressed  upwards. 

The  instrument  should  be 
longer  than  the  one  commonly  employed,  as  the  urethra  is  stretched 
by  the  enlarged  prostate,  and  its  curve  must  also  be  greater. 

It  should  always  be  borne  in  mind  in  all  cases  offering  obstruction 
to  the  free  ingress  of  the  catheter,  that  gentle  and  patient  manipulation 
will  accomplish  much  more  securely,  and  certainly  the  object  in  view, 
than  any  forcible  efforts,  which  are  liable  to  lacerate  the  urethra  and 
produce  false  passages ; and  when  these  occur  in  the  membranous  and 
prostatic  portions  of  that  canal,  fatal  suppuration 
may  be  engendered.  If  the  catheter  is  to  be  re- 
tained in  the  bladder,  it  may  be  fastened  with 
four  threads  to  a ring  prepared  of  metal  or  any 
convenient  material,  and  large  enough  to  encircle 
the  penis  in  a state  of  erection  so  that  no  con- 
striction can  possibly  happen ; the  ring  is  shoved 
up  to  the  root  of  the  penis  and  held  in  that 
position  by  threads  or  tapes  passing  upward  and 
under  the  perineum  to  a belt  around  the  waist. 

M.  Velpeau  sought  to  secure  the  same  object 
with  the  arrangement  seen  in  Fig.  589.  A piece 
of  linen  is  wrapped  around  the  penis  posterior 
to  the  glands,  and  four  threads  attached  to  the 
rings  of  the  catheter  are  then  wound  about  the 
linen  and  tied : this  plan  is  not  so  good  as  the 


Velpeau’s  method  of  fasten- 
ing a catheter. 


CATHETERISM  OF  THE  FEMALE  URETHRA. 


629 


previous  one.  inasmuch  as  it  may  produce  constriction  of  the  organ 
in  case  of  erection. 

Catheterism  of  the  Female  Urethra. — The  female  catheter  is  a silver 
tube  seven  or  eight  inches  long,  and  slightly  covered  at  its  extremity. 
It  may  be  introduced  in  the  following  manner : One  hand  is  carried 
beneath  the  bedclothes,  and  the  tip  of  the  index  finger  seeks  the  ori- 
fice of  the  urethra  below  the  junction  of  the  nymphte,  which  may  be 
known  by  an  impression  communicated  to  the  finger  resembling 
somewhat  that  received  by  pressing  it  upon  the  end  of  the  barrel  of 
a key;  then  the  catheter  held  in  the  other  hand  is  conducted  upon 
the  index  finger  into  the  urethra. 

Another  simple  plan  is  to  use  one  hand  only,  holding  the  catheter 
between  the  thumb  and  index  finger  in  the  manner  seen  in  Fig.  590. 
The  tip  of  the  instrument 
rests  beneath  the  point  of 
the  index  finger  which  feels 
for  the  meatus,  and,  when 
found,  the  instrument  may 
be  easily  slipped  into  it.  It 
is  simply  necessary  to  hint, 
that  no  exposure  of  the  pa- 
tient’s person  is  required  in 
these  manipulations. 

In  pregnant  women,  the 


Fig.  590. 


Method  of  holding  the  female  catheter. 


Fig.  591. 


Retentive  bandage  for  the  female  catheter. 


uterus,  in  its  development,  draws  up  the  urethra  some  distance,  so 
that  the  meatus  must  be  sought  a little  higher  up  than  usual,  behind 
the  lower  margin  of  the  arch  of  the  pubis;  in  such  cases,  the  male 
catheter  will,  very  often,  be  found  the  most  convenient  instrument. 


630 


REMOVAL  OF  FOREIGN  BODIES. 


During  the  descent  of  the  head  of  the  child,  the  female  urethra 
may  be  compressed,  in  which  instance  a flat  catheter  will  answer 
better  than  one  of  a cylindrical  form. 

The  neatest  retentive  bandage  for  the  female  catheter  is  arranged 
by  attaching  two  threads  to  the  rings  of  the  instrument,  and  passing 
them  around  the  upper  part  of  the  thighs,  in  which  position  they  are 
sustained  by  two  pieces  of  bandage  extending  from  the  centre  of  a belt 
around  the  waist  to  either  thread,  both  in  front  and  behind  (Fig.  591). 


CHAPTER  XIV. 

REMOVAL  OF  FOREIGN  BODIES. 

The  removal  of  foreign  bodies  from  the  various  parts  of  the  body 
demands  attentive  consideration,  as  most  cases  of  this  kind  are  sudden 
emergencies,  and  call  for  prompt  treatment,  both  to  avoid  the  morbid 
conditions  that  their  continual  presence  may  occasion,  and  to  calm 
the  apprehension  of  the  patient,  which  is  usually  considerable,  even 
in  the  least  serious  cases.  In  certain  instances  the  life  of  a person 
may  be  immediately  involved  by  the  presence  of  an  extraneous  body 
in  the  natural  cavities. 

Foreign  Bodies  in  the  Skin. — The  most  common  objects  that 
penetrate  the  skin  are  pins,  needles,  splinters  of  wood,  fragments  of 
stone,  iron,  or  glass,  and  grains  of  gunpowder.  The  removal  of  rifle 
balls,  fragments  of  shell,  and  pieces  of  clothing,  comes  naturally  under 
the  subject  of  gunshot  wounds,  and  will  therefore  be  considered  under 
that  head. 

The  hands  of  washerwomen  and  seamstresses,  and  the  knees  of 
children,  are  most  frequently  penetrated  by  pins  and  needles,  which 
may  be  either  partially  or  wholly  buried  beneath  the  skin.  In  the 
former  case,  they  may  easily  be  seized  with  the  forceps  and  extracted; 
this  cannot  often  be  effected  in  the  latter  instance,  for  the  object  may 
be  entirely  concealed  from  the  most  scrutinizing  examination,  or  at 
least  can  only  be  felt  and  moved  beneath  the  skin  with  the  fingers. 
Needles  have  remained  imbedded  in  the  tissues  for  years  without 
causing  the  slightest  trouble ; in  other  instances  they  have  produced 
soreness  and  stiffness  of  the  muscles,  and  suppuration. 

When  the  object  can  be  felt,  it  should  be  removed  by  steadying  it 
with  the  fingers,  and  making  an  incision  dowrn  upon  it,  when,  with 
the  forceps,  it  may  easily  be  seized  and  extracted.  Exploratory 
incisions  should  never  be  made,  as  it  can  rarely  happen  that  the 
body  will  be  found.  Mr.  Erichsen  recommends,  for  the  purpose  of 
extracting  needles,  thorns,  splinters  of  wood,  and  other  foreign  bodies 
of  small  size  and  pointed  shape,  lying  in  narrow  wounds,  the  forceps 
shown  in  Fig.  592.  They  have  very  fine,  but  strong  and  well-serrated 
points. 


REMOVAL  OF  FOREIGN  BODIES. 


631 


Sometimes  a needle  penetrates  the  knee-joint  of 
children  while  romping  upon  the  floor ; and  in  two 
cases  of  the  kind  which  have  come  under  my  notice, 
the  inflammation  excited  by  it  resulted  in  anchy- 
losis. The  joint  should  be  kept  quiet  for  a few  days, 
and  recourse  had  to  cold  water-dressings,  or  other  anti- 
phlogistics,  should  inflammation  arise.  If  the  needle 
can  be  felt,  it  may  be  pressed  as  near  the  surface  as 
possible,  and  removed  through  a valvular  incision. 

Workmen  in  wood  often  run  splinters  into  the 
skill,  or  what  is  yet  more  painful,  under  the  nail. 

They  may  be  removed  with  the  point  of  a needle  or  a 
bistoury,  pressed  beneath  their  projecting  extremity, 
to  lift  them  from  their  bed.  Softened  with  the  mois- 
ture of  the  parts  in  which  they  stick,  splinters  some- 
times break  in  two,  and  leave  no  projecting  end  to  be 
seized  by  the  forceps;  in  such  a case  it  will  be  neces-  Enchsen’s  forceps  for 
sary  to  run  the  point  of  a bistoury  the  whole  length  removing foreign  bo- 

of  the  splinter,  and  then  dislodge  it  with  the  forceps.  ^esnomtueskm. 

A large  splinter,  run  beneath  the  nail,  causes  severe  pain ; and  if 
it  cannot  be  extracted  with  the  forceps,  the  nail  should  be  split  up  in 
the  direction  of  the  foreign  body. 

In  blasting  rock,  fragments  of  stone  may  be  driven  into  the  tissues ; 
the  general  rule  in  such  cases  is,  to  remove  the  objects  immediately, 
if  they  can  be  felt,  through  an  incision  made  upon  them. 

Grains  of  gunpowder,  in  explosions,  sometimes  stick  into  the  skin 
of  the  face  and  hands.  When  the  grains  are  not  numerous,  they  may 
be  taken  out  with  the  point  of  a needle ; but  in  the  majority  of  cases, 
neither  the  surgeon  will  feel  inclined  to  undertake,  nor  the  patient  dis- 
posed to  undergo,  such  a tedious  operation.  It  has  been  recommended 
to  apply  a blister  to  the  part  for  three  or  four  hours,  then  to  remove  it 
and  substitute  a poultice ; a more  successful  and  agreeable  plan,  how- 
ever, is  to  layover  the  discolored  surface,  with  a camel’s-hair  brush,  a 
solution  of  corrosive  sublimate  in  glycerine  (gr.  ij  to  fsj).  This  solu- 
tion does  not  dissolve  the  powder,  but  causes  the  little  pits  in  which 
the  grains  are  imbedded  to  suppurate  and  discharge  them. 

Gold  and  silver  rings  may  constrict  the  fingers  and  require  removal ; 
if  there  is  not  much  tumefaction  it  may  be  accomplished  with  a fine 
file ; they  may  also  be  worked  off  if  a piece  of  tape  can  be  gotten 
beneath  them,  but  the  most  ingenious  plan  is  to  convert  them  into  an 
alloy  with  mercury,  when  they  can  be  easily  crushed  beneath  the 
fingers. 

A case  came  under  my  notice  where  a boy  having  been  punished 
for  wetting  his  bed,  and  feeling  his  inability  to  prevent  a recurrence 
of  the  involuntary  discharge,  tied  a string  about  the  penis.  Inflam- 
mation and  swelling  succeeded ; so  as  to  hide  it  from  view,  and  urina- 
tion became  impossible;  the  boy  would  give  no  information  concerning 
the  matter  until  the  severe  pain  which  it  caused  compelled  him  to^ 
divulge  the  secret. 


Fig.  592. 


632 


REMOVAL  OF  FOREIGN  BODIES. 


The  cord  was  snipped  with  the  scissors,  and  all  the  bad  symptoms 
disappeared. 

Foreign  Bodies  in  the  Eye.— The  surgeon  has  more  frequently 
to  deal  with  foreign  bodies  in  the  eye  than  in  any  of  the  other  organs. 
They  cause  severe  pain,  intolerance  of  light,  and  a profuse  secretion 
of  tears;  the  conjunctiva  becomes  congested,  and  not  uncommonly  its 
enlarged  vessels  cause  the  patient  to  experience  a sensation  as  if  the 
foreign  body  was  still  in  the  eye,  after  its  removal.  * 

Cinders,  spiculae  of  iron,  of  steel,  or  stone,  and  sand,  are  the  foreign 
objects  that  most  often  gain  admission  into  the  eye.  When  they 
simply  repose  upon  the  conjunctiva,  the  constant  winking  and  flow  of 
tears  which  they  produce,  with  the  rubbing  which  the  patient  usually 
inflicts  upon  the  organ,  not  unfrequently  carry  away  the  offending 
cause.  Should  this  not  occur,  the  eyre  may  be  exposed  to  a good  light, 
and  while  he  holds  the  lids  apart,  the  operator  may  remove  the  object 
with  the  point  of  a camel’s-hair  brush,  the  corner  of  a pocket  hand- 
kerchief, the  eye  of  a needle,  or  the  bulbous  extremity  of  a probe. 
To  explore  the  inner  surfaces  of  the  eyelids  they  should  be  everted ; 
the  upper  one,  by  drawing  out  the  lid  with  the  forefinger  and  thumb 
of  the  left  hand,  while  pressure  is  made  upon  its  upper  surface  with 
the  pulp  of  the  right  index  finger,  or  preferably  the  point  of  a probe 
or  lead  pencil ; the  lower  lid  is  easily  exposed  by  simply  drawing  it 
down  upon  the  cheek. 

The  most  difficult  objects  to  remove  are  little  bits  of  iron  or  steel 
when  they  become  imbedded  in  the  conjunctiva;  the  greatest  gentle- 
ness and  patience  should  be  exercised  in  these  cases  lest  irreparable 
injury  be  done  to  the  structure  of  the  eye. 

The  best  plan  is,  after  securing  the  benefit  of  a good  light,  to  place 
the  point  of  a cataract-needle  (or  a common  one  will  do  very  well) 
beneath  the  bit  of  metal  and  lift  it  from  its  bed.  After  the  removal 
of  the  intruder,  cold  water  applications  will  be  found  both  agreeable 
to  the  sensations  of  the  patient  and  beneficial  in  checking  inflamma- 
tory action.  A drop  of  glj'cerine  placed  between  the  lids  will  also 
produce  an  agreeable  sensation  of  relief. 

Foreign  Bodies  in  the  Ear,— Beans,  peas,  beads,  small  pebbles, 
insects,  particularly  the  earwig,  and  similar  bodies  sometimes  gain  ad- 
mission into  the  external  meatus  either  accidentally  or  intentionally. 
They  occasionally  produce  intense  pain,  especially  those  that,  being 
absorbent  and  swelling,  distend  the  auditory  canal.  The  cerumen 
may  also  collect  in  hard  pellets  and  occasion  deafness,  singing  in  the 
ears,  and  dizziness. 

In  children,  the  irritation  from  a foreign  body  in  the  ear  may  be  so 
great  as  to  produce  convulsions. 

The  ear  in  these  cases  should  be  carefully  examined  by  placing  the 
patient’s  head  in  such  a position  that  the  rays  of  a strong  light  may  be 
concentrated  in  the  meatus,  which  should  be  straightened  as  much  as 
possible  by  drawing  the  auricle  upwards  and  backwards.  Or  a 
speculum  may  be  used,  that  of  Mr.  Toynbee,  of  Dublin,  is  the 
best  (Fig.  593).  Wilde’s  instrument,  seen  in  Fig.  594,  sometimes 


FOREIGN  BODIES  IN  THE  EAR. 


683 


employed,  is  conical  in  shape  and  causes  a good  deal  of  pain  when 
the  lining  membrane  of  the  meatus  is  much  swollen  and  tender.  I 
have  been  in  the  habit,  for  several 
years,  of  using  the  illuminating  Fig.  593. 
otoscope,  seen  in  Fig.  595,  which  I 
prefer  to  all  others ; for  with  a lit- 
tle practice,  the  meatus  and  mem- 
brane of  the®tympanum  may  both 
he  beautifully  illuminated,  and  I 
have  succeeded  in  discovering  a 
foreign  body,  in  this  manner,  when 
other  instruments  have  failed  me. 

In  using  the  otoscope,  the  tube  is 
introduced  into  the  meatus  with  the 
funnel,  b,  of  the  instrument  look- 
ing backwards ; in  front  of  the  lat- 
ter a steady  flame  is  put  so  that  the 

rays  of  light  may  strike  upon  the  polished  metal  mirror,  c,  which 
throws  the  rays  in  the  direction  of  d e,  into  the  meatus ; the  eye  of  the 

Fig.  595. 


Toynbee’s  ear  speculum.  Wilde’s  ear  speculum* 


observer  placed  at  a can  now  see  the  membrane  of  the  tympanum 
illuminated  through  the  tube  a d e,  which  is  movable,  to  enable  the 
surgeon  to  adjust  the  focus  of  a convex  lens  located  at  e. 

The  simplest  and  at  the  same  time  most  efficient  way  of  dislodging 
an  extraneous  object  in  the  meatus  is  by  throwing  a stream  of  water 
into  it  in  the  manner  described  at  page  108. 


Fig.  596. 


Instrument  for  removing  foreign  bodies  from  the  ear. 


Should  this  not  succeed,  an  eyed  probe  may  be  bent  a little  at  its 
extremity,  and  used  as  a hook  to  draw  the  body  forwards ; a curette 
will  sometimes  answer  the  same  purpose  (Fig.  596). 

Mr.  Toynbee  recommends  a pair  of  rectangular  forceps,  which  will 
enable  the  surgeon  to  look  into  the  auditory  canal  while  the  instru- 
ment is  being  used  in  seizing  the  object  (Fig.  597). 


634  REMOVAL  OF  FOREIGN  BODIES. 

Fig.  597. 


Toynbee’s  forceps  for  removing  foreign  bodies  from  the  meatus. 


Dr.  Hewson,  of  Philadelphia,  has  constructed  a pair  of  forceps  bent 
at  their  articulation ; the  blades  are  separable  from  each  other,  and 

form  at  their  extremities  little 
oval  rings,  which  are  well  adapt- 
ed for  seizing  hold  of  rounded 
objects;  a single  blade  may  be 
used,  if  necessary,  as  a lever. 

Dr.  Corse,  of  the  same  city, 
devised  for  this  purpose  the  in- 
strument represented  in  the  an- 
nexed wood-cut  (Fig.  599),  and 
described  by  him  in  the  Ameri- 
can Journal  of  the  Medical  Sci- 
ences for  October,  1858.  It  consists  of  two  equal  sections  of  a cylinder, 
rounded  at  one  end,  and  fenestrated  at  the  other ; these  are  connected 


Fig.  599. 


Corse’s  instrument  for  removing  foreign  bodies  from  the  ear. 


together  by  a small  piece  of  metal  bearing  two  little  pins  upon  either 
side,  which  slide  into  the  fenestra.  By  this  arrangement,  the  blades 
can  be  introduced  into  the  meatus  singly,  and  theu  united  by  the  pins. 

The  canula-forceps  may  also  be  used  for  seizing  small  bodies,  but 
they  are  not  nearly  so  efficient  or  manageable  as  the  foregoing  instru- 
ments. 

Insects  may  be  suffocated  by  filling  the  meatus  with  sweet  oil  or 
glycerine,  and  then  washed  out  with  the  syringe. 

Concreted  cerumen,  as  stated  above,  sometimes  causes  deafness  and 
irritation  of  the  auditory  canal : the  plan  to  follow  in  this  case  is  first 
to  soften  the  wax  with  a solution  of  the  carbonate  of  soda  in  water 
(gr.  x to  fsj),  and  then  to  wash  it  out  with  warm  water  or  to  scoop  it 
out  with  a curette. 

Should  the  removal  of  any  of  the  foreign  bodies  be  likely  to  cause 
much  suffering  to  the  patient,  the  administration  of  chloroform  will 
be  requisite. 

The  after-treatment  will  consist  in  combating  local  inflammation  by 
the  application  of  leeches  first,  and  then  emollient  dressings. 


Fig.  598. 


FOREIGN  BODIES  IN  PHARYNX  AND  (ESOPHAGUS.  635 

Foreign  Bodies  in  the  ISTose. — Buttons,  beans,  or  beads  are  some- 
times thrust  into  the  nose  by  children  in  their  play  ; they  often  cause 
considerable  irritation  and  inflammation  of  the  mucous  membrane, 
which  swells  up,  and  closes  the  nares  so  as  to  give  a good  deal  of 
trouble  in  removing  them. 

The  eye-probe,  bent  at  its  point,  may  be  used  as  a hook  to  draw 
out  the  intruder,  or  a canula  with  a wire  loop  running  through  it. 

Sometimes  the  injection  of  water,  either  from  before  backwards  or 
the  reverse,  will  succeed  ; in  the  former  case  the  object  will  of  course 
be  carried  into  the  pharynx,  from  which  it  can  readily  be  expelled  by 
the  voluntary  efforts  of  the  patient. 

Causing  the  patient  to  -sneeze  violently  by  snuff  or  other  sternu- 
tatories, while  the  mouth  is  held  shut,  may  also  dislodge  the  foreign 
body. 

Foreign  Bodies  in  the  Pharynx  and  (Esophagus. — Small  ob- 
jects, such  as  bristles,  needles,  pins,  buttons,  coins,  fragments  of  fish 
or  chicken  bone,  sometimes  lodge  about  the  base  of  the  tongue,  in  the 
lower  part  of  the  pharynx  or  oesophagus,  causing  an  uneasy  sensation 
in  the  throat  and  a constant  disposition  to  hawk  and  cough.  Should 
the  body  be  larger,  and  become  impacted  behind  the  larynx,  as  occurs 
from  a morsel  of  meat  being  arrested 
at  this  point  of  the  oesophagus,  the 
most  distressing  symptoms  of  suffo- 
cation are  produced,  and  death  may 
result  from  suffocation. 

Prompt  action  is  required  in  the 
treatment  of  these  cases;  the  sur- 
geon should  first  throw  the  patient’s 
head  back,  and  pass  his  index  fin- 
J ger  into  the  pharynx ; he  may  suc- 
| ceed  in  this  manner  either  in  fishing 
out  the  object,  or  shoving  it  beyond 
the  larynx  if  suffocation  is  threat- 
ened ; though  it  will  be  better,  should 
delay  be  possible,  and  the  object 
indigestible,  irregular  in  shape,  or 
likely  to  injure  the  mucous  mem- 
brane of  the  stomach,  to  remove  it 
with  a pair  of  forceps.  Those  most 
likely  to  be  at  hand  will  be  the 
dressing  forceps,  which  will  answer 
very  well  if  the  object  is  not  too  far 
; down ; the  best  instruments,  however, 
for  the  purpose  are  the  forceps  seen 
in  Figs.  600  and  601,  devised  by  Dr. 

Bond,  of  Philadelphia ; in  one  pair 
the  blades  are  curved  at  right  angles 
with  the  rivet,  and  in  the  other  in 
the  same  plane  with  it;  their  inner  margins  are  bevelled  outwards, 
leaving  a line  of  serration  only  at  their  centres ; an  arrangement  that 


Fig.  600.  Fig.  601. 


636 


REMOVAL  OF  FOREIGN  BODIES. 


will  prevent  the  mucous  membrane  of  the  gullet  being  pinched  between 
them  when  the  forceps  are  closed. 

In  using  this  instrument  the  head  of  the  patient  is  thrown  back,  and 
the  blades  of  the  forceps  glided  over  the  tongue  into  the  oesophagus, 
as  seen  in  Fig.  602. 

It  may  be  observed  that  the  constant  motion  of  the  tongue  will 
sometimes  render  these  manipulations  about  the  throat  troublesome ; 


this  may  be  obviated  in  a great  measure  by  letting  the  patient  inhale 
a few  whiffs  of  chloroform. 

If  the  finger  should  not  be  long  enough  to  shove  the  object  beyond 
the  larynx,  a probang  will  enable  the  surgeon  to  accomplish  this,  and 
if  necessary  press  it  also  into  the  stomach. 

Dr.  Bond  contrived  a hook  made  of  copper  wire  silvered,  or  silver 
wire,  of  the  shape  presented  in  Fig.  603,  for  the  purpose  of  removing 
pins  or  coins ; it  is  to  be  passed  into  the  oesophagus  beyond  the  object, 
and  then  drawn  up  to  catch  it  in  the  hook. 

A useful  instrument  for  the  removal  of  needles,  bristles,  and  similar 
objects,  is  shown  in  Fig.  604 ; it  is  composed  of  a metallic  stem  and 
sheath  mounted  with  bristles,  connected  with  them  in  such  a manner 
that  by  moving  the  stem  the  bristles  are  made  to  expand  laterally, 
and  fill  up  the  oesophagus ; and  when  the  instrument  is  withdrawn  it 
sweeps,  so  to  speak,  the  whole  length  of  that  canal. 

Prof.  Gross  recommends  an  excellent  instrument  for  extracting 
foreign  bodies  from  the  gullet.  It  consists,  as  seen  in  Fig.  605.  of  a 
metallic  tube  fifteen  inches  long,  and  slightly  curved ; through  this 
runs  a slender  rod,  bearing  at  its  extremity  four  little  wing-like 


Fig.  602. 


Fig.  603. 


Mode  of  introducing  the  forceps  into  the  gullet. 


Bond's  gullet  hoot. 


FOREIGN  BODIES  FROM  LARYNX  AND  TRACHEA.  637 


apparatus,  which  may  be  open  or  FlS-  604-  Fls-  605- 

shut  at  pleasure  by  turning  the 
handle  of  the  instrument. 

Dr.  Bright,  of  Kentucky,  had 
recourse  to  an'  ingenious  expe- 
dient for  removing  a fish-hook 
attached  to  a cord,  that  had  been 
swallowed.  He  perforated  a lea- 
den ball  with  a hole;  through 
this  he  passed  the  string  con- 
nected with  the  hook,  against 
which  the  ball  was  pressed.  In 
this  manner  the  point  of  the 
hook  was  guarded,  while  the  sur- 
geon took  hold  of  the  cord  and 
withdrew  the  ball  and  hook  to- 
gether safely. 

An  emetic  of  mustard  or  the 
sulphate  of  zinc  will  often  suc- 
ceed in  dislodging  the  extrane- 
ous object  from  the  gullet ; it 
should  be  assisted  by  drinking 
freely  of  water  or  some  demul- 
cent fluid. 

Foreign  bodies  that  have  en- 
tered the  oesophagus  may  remain 
in  that  canal  without  causing 
any  trouble  for  a long  time,  or 
they  may  escape  into  the  blood- 
vessels, or  other  organs  of  the 
thoracic  cavity,  and  produce  fatal 
hemorrhage,  or  inflammation 
and  suppuration.  In  other  cases 
the  object  slips  into  the  stomach, 
remains  there  for  a longer  or 
shorter  time,  and  is  finally  voided 
by  stool ; or  the  intestines  may 
be  perforated,  and  the  object  ulti- 
mately emerge  from  the  skin. 

The  after-treatment  requires 
the  use  of  emollient  fluids,  if  the  foreign  bodies  produce  irritation  of 
the  oesophageal  or  gastric  mucous  membrane. 

Removal  of  Foreign  Bodies  from  the  Larynx  and  Trachea. 
— From  carelessness  in  holding  small  objects  in  the  mouth,  they  are 
sometimes  accidentally  drawn  into  the  larynx  and  trachea  during  the 
inspiratory  act,  giving  rise  to  a most  distressing  condition,  which  calls 
often  for  immediate  surgical  interference  to  save  life. 

The  articles  that  commonly  intrude  themselves  in  this  manner  are 
coins ; seeds  of  certain  fruits,  as  the  cherry  and  plum ; grains  of  corn 


638 


REMOVAL  OF  FOREIGN  BODIES. 


and  coffee;  beans;  bits  of  meat;  buttons;  pebbles;  cockle-burs;  teeth  in 
several  recorded  cases ; and  a number  of  other  substances.  According 
to  their  size,  shape,  weight,  and  the  condition  of  their  surface  as  to 
smoothness,  they  occupy  different  portions  of  the  air-passages : those 
that  are  light,  sharp-pointed,  or  covered  with  projecting  points,  may 
stick  at  the  superior  orifice  of  the  larynx,  or  catch  when  they  arrive 
at  its  ventricles ; while  those  that  are  round,  heavy,  and  smooth, 
will  generally  glide  through  the  larynx  and  trachea,  and  lodge  in  the 
bronchi ; the  right  one,  from  its  size  and  position,  being  most  frequently 
penetrated.  The  object  may  be  fixed  at  any  point,  or  move  up  and 
down  through  the  whole  length  of  the  larynx  and  trachea. 

The  results  which  most  commonly  follow  from  the  retention  of  a 
foreign  substance  in  the  air-passages  are  inflammation  of  the  mucous 
membrane  lining  them ; pneumonia  of  a portion  or  the  entire  of  one 
lung,  corresponding  with  the  bronchi  in  which  the  body  is  located ; 
phthisis ; pulmonary  emphysema ; and  lastly  emaciation. 

The  symptoms  produced  are  those  characteristic  of  obstructed 
respiration  ; the  patient  coughs  violently,  gasps  for  breath,  seizes  his 
throat  as  if  to  tear  away  some  obstruction  there ; stares  about  him 
wildly ; and  not  unfrequently  falls  down  unconscious.  The  face 
becomes  livid  and  swollen ; and  there  is  more  or  less  expectoration 
of  mucous  matter,  occasionally  accompanied  with  blood,  during  the 
fits  of  coughing.  This  paroxysm  lasts  from  a few  seconds  to  several 
minutes,  or  even  longer,  when  the  breathing  becomes  more  tranquil 
and  the  severity  of  the  symptoms  diminish.  Thus  the  patient  will  be 
harassed  with  alternate  paroxysms  of  these  distressing  symptoms  and 
periods  of  abatement,  until  he  either  dies  suffocated,  or  worn  out  by 
consecutive  disease  of  the  thoracic  viscera.  Cases  have  been  observed 
in  which  none  of  the  above  phenomena  were  present,  or,  if  so,  in  a 
very  mild  degree. 

The  cough  is  at  times  of  a spasmodic  character,  resembling  that  of 
croup,  so  as  to  render  the  diagnosis  of  the  case  difficult ; other  of  the 
symptoms  have  also  been  so  simulated  by  those  of  catarrh,  pneumonia, 
and  phthisis,  as  to  embarrass  the  judgment  of  the  practitioner. 

An  accurate  inquiry  into  the  history  of  the  case,  with  a careful 
physical  examination  of  the  chest,  is  the  only  means  of  arriving  at 
a correct  conclusion  in  such  instances. 

When  the  diagnosis  has  been  clearly  made  out,  an  effort  should  be 
made  by  the  surgeon  to  dislodge  the  foreign  body  from  the  air- 
passages  by  placing  the  patient  in  such  a position  that  the  head  and 
chest  may  be  lower  than  the  rest  of  the  body,  when  the  back  should 
be  struck  with  quick  blows  with  the  hand ; in  this  manner  the  foreign 
substance  may  be  started,  so  that  it  will  escape  through  the  glottis,  as 
was  successfully  done  in  the  well-known  case  of  the  English  engineer. 
Brunei,  recorded  by  Sir  B.  Brodie ; a half  sovereign  had  accidentally 
slipped  into  this  gentleman’s  trachea  while  amusing  some  children. 

The  foreign  body  will  in  some  cases  be  expelled  by  violent  efforts 
at  coughing. 

Should  this  process  fail,  nothing  remains  but  to  perform  the  opera- 


FOREIGN  BODIES  FROM  URETHRA  AND  BLADDER.  639 


tion  of  laryngotomy  or  tracheotomy,  and  to  extract  the  foreign  body 
with  properly  constructed  forceps. 

After  the  patient  has  been  relieved  from  the  presence  of  the  object 
in  the  windpipe,  he  is  not  always  secure  of  his  life,  inasmuch  as  the 
inflammatory  condition  of  the  mucous  membrane  of  the  air-passages 
and  lungs  excited  by  it,  may  lead  to  a fatal  termination.  These  com- 
plications should  engage  the  earnest  attention  of  the  medical  attendant, 
that  they  may  be  combated  by  appropriate  measures. 

Removal  of  Foreign  Bodies  from  the  Urethra  and  Bladder. 
— The  urethra  may  become  obstructed  by  the  presence  in  it  of  frag- 
ments of  calculi,  clots  of  blood,  concrete  mucus,  or  fragments  of 
bougies  which  have  broken  off  the  instrument  during  its  introduction. 
In  other  cases,  persons  have  designedly  put  into  the  canal  sticks,  slate- 
pencils,  or  hair-pins.  They  may  occupy  any  portion  of  the  urethra ; 
and  give  rise  to  retention,  local  inflammation,  and  pain. 

When  near  the  orifice,  their  removal  may  be  effected  by  seizing  them 
in  the  jaws  of  a pair  of  finely-pointed  forceps  (Fig.  611),  or  with  a bent 
probe,  curette,  or  a loop  of  fine  wire, 
ally  be  pressed  towards  the  meatus, 
and  removed  in  the  manner  above 
mentioned ; or,  if  this  cannot  be  done, 
perhaps  a large-sized  catheter  intro- 
duced down  to  the  obstruction,  so 
as  to  dilate  the  urethra  and  permit 
the  foreign  body  to  move  forwards 
by  the  pressure  of  the  urine  behind, 
may  succeed. 

Mr.  Weiss,  of  London,  has  in- 
vented an  instrument  for  dilating 
the  urethra,  shown  in  the  annexed 
wood-cut  (Fig.  606);  it  consists  sim- 
ply of  a metallic  stem  divided  into 
two  equal  segments,  and  capable  of 
being  expanded  to  the  required  ex- 
tent, so  that  the  points  of  the  forceps 
may  be  introduced. 

Many  ingenious  urethral  forceps 
have  been  devised  for  the  purpose  of  seizing  hold  of  the  intruding 
substance  and  removing  it.  Fig.  607  shows  an  instrument  composed 

Fig.  607. 


If  further  in,  they  may  occasion- 
Fig.  606. 


Weiss’s  urethral  dilator. 


Urethral  forceps. 


of  three  slender  branches,  which  are  inclosed  in  a canula,  and  when 
brought  down  to  the  object,  may  be  protruded  to  grapple  it. 

Weiss’s  forceps  consist,  as  seen  in  Fig.  608,  of  two  blades,  B,  inclosed 


64:0 


REMOVAL  OF  FOREIGN  BODIES. 


in  the  canula  A,  for  seizing  the  fragment  of  calculus,  while  it  may  he 
reduced  to  powder  by  the  drill  working  between  them. 

Fig.  608. 


Weiss’s  forceps. 

A convenient  instrument  will  be  found  in  the  scoop-pointed  canula 
with  a narrow  tongue  moved  by  a central  stem,  as  seen  in  Fig.  609, 

Fig.  609. 


Instrument  for  removing  foreign  todies  from  the  urethra. 

or  the  double-bladed  forceps  delineated  in  Fig.  610,  which  consists  of 
two  narrow  blades  concealed  in  the  canula  (a),  and  capable  of  being 
expanded  by  being  thrust  forwards,  and,  when  the  foreign  substance 


Fig.  610. 


Double-bladed  urethral  forceps. 


is  grappled,  closed  again  by  simply  shoving  the  canula  upon  them ; 
the  screw  D regulates  the  distance  between  the  blades. 

In  manipulating  with  these  instruments,  the  finger  should  be  placed 
upon  the  foreign  body,  to  prevent  its  moving  while  it  is  being  seized. 
Should  the  surgeon  fail  with  the  forceps,  nothing  remains  but  to 


Fig.  611. 


cut  down  upon  the  urethra  and  remove  the  obstructing  substance; 
and,  if  it  is  possible,  this  should  be  pressed  into  the  membranous 


REMOVAL  OF  FOREIGN  BODIES  FROM  THE  RECTUM.  641 

portion  of  the  canal,  and  the  incision  made  upon  the  perineum,  for 
the  reasoD  that  wounds  of  the  membranous  urethra  heal  with  much 
greater  celerity  and  certainty  than  those  anterior  to  the  bulb. 

The  female  urethra  is  short  and  very  dilatable,  and  little  difficulty 
will  therefore  be  encountered  in  removing  extraneous  substances  from 
it;  for  this  purpose  the  delicate  pair  of  forceps  seen  in  Fig.  611  will 
answer  very  well. 

Removal  of  Foreign  Bodies  from  the  Yagina. — Large  objects 
may  be  introduced  into  the  vagina,  either  by  the  patient  herself,  under 
some  unnatural  excitement,  or,  criminally,  by  another  person  ; or  cer- 
tain instruments,  such  as  pessaries,  that  have  been  employed  in  the 
treatment  of  uterine  disease,  are  permitted  to’remain  in  the  canal  until 
they  produce  great  derangements  of  health,  and,  in  some  cases,  ulcera- 
tion into  the  rectum  or  bladder.  M.  Cloquet  reports  a case  in  which 
a cork  pessary  remained  in  the  vagina  ten  years. 

For  the  removal  of  these  objects,  great  delicacy  of  manipulation  is 
required.  The  vagina  should  be  first  syringed,  to  clear  away  all  ad- 
hering mucosities;  a speculum  is  then  introduced,  and  its  walls  dilated ; 
when  the  object  is  thus  brought  into  view,  it  may  be  seized  with  the 
forceps  and  withdrawn.  If  the  body  is  large  and  impacted,  it  may 
become  necessary  to  divide  the  sphincter. 

Removal  of  Foreign  Bodies  from  the  Rectum. — Foreign  sub- 
stances are  sometimes  introduced  into  the  rectum  by  design,  such  as 
pebbles,  pieces  of  wood,  vials,  and  bougies ; or  they  are  ingested,  and 
become  entangled  in  the  folds  of  mucous  membrane  just  within  the 
sphincter;  of  these  the  most  frequent  are  the  seeds  of  fruits,  such  as 
cherries,  grapes,  &c.  In  old  people,  especially  females,  the  feces  become 
impacted  in  the  rectum,  even  in  some  cases  as  high  as  the  sigmoid 
flexure,  giving  rise  to  derangements  of  digestion,  loss  of  sleep,  pain 
and  a sensation  of  fulness  in  the  bowel;  the  patient  passes  a thin  mu- 
coid fluid,  often  tinged  with  blood,  so  as  to  lead  the  medical  attendant 
to  suspect  the  presence  of  dysentery. 

The  removal  of  the  feces  is  effected  by  breaking  down  the  hard- 
ened mass  with  the  finger,  well  oiled,  and  passed  into  the  gut ; should 
this  not  be  long  enough  to  reach,  the  handle  of  a tablespoon  may  be 
used,  or  the  ordinary  scoop  employed  in  lithotomy  (Fig.  612)  to  clear 

Fig.  612. 


Scoop  for  removing  foreign  bodies  from  the  rectum. 


the  bladder  of  the  debris  of  calculi.  A copious  stream  of  warm  water 
must  also  be  thrown  into  the  bowel,  with  the  India-rubber  ball 
syringe  attached  to  a long  muzzle,  or  the  tube  of  the  stomach-pump, 
to  soften  the  feces,  which  will  render  the  operation  less  painful. 
When  small  objects  are  present,  they  may  be  seized  with  the  forceps 
and  withdrawn;  and  larger  ones  may  be  crushed  with  a strong  in- 
strument and  removed  piecemeal,  as  was  done  by  Dr.  Parker,  of 
41 


642  ON  THE  MODES  OF  ARRESTING  HEMORRHAGE. 

Canton,  in  the  case  of  a Chinaman,  into  whose  rectum  a glass  goblet 
had  been  thrust. 

In  the  case  recorded  by  Marcetti,  of  a courtesan  who  bad  the  butt- 
end  of  a pig’s  tail,  rendered  rough  by  having  its  bristles  cut  off 
forced  into  her  rectum  by  some  students,  the  removal  was  accom- 
plished by  slipping  a piece  of  reed  over  the  pig’s  tail,  to  which  a cord 
was  attached,  so  as  to  protect  the  rectal  mucous  membrane.  In  the 
same  manner  any  rough  object  may  be  extracted  through  a large 
metallic  tube. 


CHAPTER  XV. 

ON  THE  MODES  OF  ARRESTING  HEMORRHAGE. 

Hemorrhage,  whether  proceeding  from  accidental  wounds  or  from 
those  following  the  employment  of  the  surgeon’s  knife — or  whether  ii 
rushes  in  angry  torrents  from  any  part  of  the  body  in  consequence  o 
disease,  is  always  a serious  misfortune,  and  often  involves  the  safety 
of  the  patient’s  life  by  its  quantity  or  continuance. 

In  that  variety  of  hemorrhage  arising  from  the  first  two  causes, 
which  principally  concerns  us  here,  the  blood  may  issue  from  the 
capillaries,  veins,  or  arteries. 

Capillary  hemorrhage  rarely  takes  place  to  any  considerable  extent 
unless  it  be  in  those  persons  laboring  under  the  hemorrhagic  dia- 
thesis, or  in  whom  the  blood  has  undergone  morbid  changes,  and  the 
constitutional  powers  are  broken  down  by  great  fatigue,  improper  or 
insufficient  food,  or  other  causes. 

Venous  hemorrhage,  when  from  small  vessels,  usually  quickly 
ceases  by  the  collapse  of  their  walls ; if  the  veins  are  larger,  or  so 
connected  with  the  surrounding  tissues  that  their  walls  cannot  fall 
together,  the  hemorrhage  will  take  place  freely ; the  blood,  which  is 
of  a dark  color,  runs  from  the  wound  in  a continuous  stream,  and  is 
increased  in  quantity  by  a ligature  placed  around  the  limb  above  the 
part  injured;  the  lower  extremity  of  the  vein  always  supplying  the 
blood,  except  in  a few  cases  where  the  vessel  is  too  large  to  be 
closed  completely  by  the  valves  with  which  it  is  provided;  in  this 
case  the  blood  will  flow  from  both  ends  of  the  vein. 

Arterial  hemorrhage,  as  its  name  implies,  springs  from  the  arteries, 
and  is  the  variety  which  the  surgeon  is  most  frequently  called  upon 
to  control.  The  vessels  may  be  partially  or  completely  divided,  or 
the  wound  may  be  transverse  or  longitudinal  to  their  axis.  The  blood 
escapes  per  saltum,  as  it  is  designated— that  is,  in  jets  isochrouous 
with  the  contractions  of  the  heart ; and  it  is  florid,  and  more  or  less 
frothy.  Pressure  in  the  course  of  the  vessel  above  the  wound, 
diminishes  or  arrests  it.  In  deep  or  sinuous  wounds  the  blood  may 
simply  well  up,  instead  of  escaping  per  saltum,  as  it  usually  does,  in 


ON  THE  MODES  OF  ARRESTING  HEMORRHAGE.  643 

consequence  of  its  force  being  broken  by  striking  against  their  walls ; 
but  the  red  color  remains,  to  distinguish  it  from  venous  blood. 

In  wounds  of  the  large  arteries  of  the  limbs,  the  condition  of  the 
circulation  in  the  latter  will  depend  upon  the  point  at  which  the 
injury  is  inflicted.  If  the  trunk  is  cut  through  high  up,  above  the 
large  anastomotic  branches,  pulsation  cannot  be  felt  in  the  vessels 
below;  while,  on  the  other  hand,  if  these  branches  are  above  the 
wound,  this  pulsation  will  be  only  diminished.  In  the  former  case, 
the  upper  extremity  of  the  artery  alone  pours  out  blood  ; and  in  the 
latter,  both  extremities  bleed.  The  blood  usually  escapes  from  the 
lower  orifice  in  a continuous  stream,  as  in  the  veins;  but  if  the  circu- 
lation is  rapid,  and  the  anastomosis  undisturbed,  the  stream  may  leap 
forth  per  saltum. 

When  an  artery  of  large  size  is  cut  in  two,  the  blood  gushes  out 
rapidly,  and,  if  not  instantly  checked,  the  patient  dies  in  a few 
seconds.  The  hemorrhage  from  smaller  arteries  is  less  copious,  and 
after  a certain  quantity  has  escaped,  the  patient  faints,  and  thereby 
the  force  of  the  circulation  is  diminished;  the  ends  of  the  severed 
artery  retreat  amidst  the  surrounding  cellular  tissue ; and  they  also 
contract  so  as  to  bring  the  margins  of  the  divided  inner  coats  in  con- 
tact, and  diminishing  the  canal  immediately  above.  The  blood  in  the 
vessel  coagulates  as  high  up  as  the  first  collateral  branch  above,  form- 
ing a sort  of  internal  plug,  while  an  effusion  of  plastic  matter  at  the 
orifice  of  the  vessel  serves  the  purpose  of  an  external  plug.  By 
the  combined  action  of  these  conditions,  the  hemorrhage  is  naturally 
arrested,  and  no  more  bleeding  occurs  in  some  cases ; in  other  instances 
as  soon  as  reaction  is  established,  the  hemorrhage  is  renewed  in  con- 
sequence of  the  increased  force  of  the  circulation  forcing  the  clots 
from  the  mouth  of  the  artery.  This  may  occur  again  and  again 
until  the  vessel  is  tied  or  the  patient  dies  exhausted.  This  is  called 
intermediary  hemorrhage.  Should  the  vessel  be  partially  divided — 
say  a quarter  of  its  circumference — the  blood  will  escape  per  saltum, 
but  not  so  freely  as  in  the  former  case,  because  a part  of  it  keeps  on 
in  its  natural  course.  In  this  case,  if  pressure  is  made  over  the  in- 
jured part,  the  wound  in  the  artery  may  heal  up.  If  half  or  three- 
fourths  of  the  circumference  be  divided,  no  contraction  of  the  wounded 
artery  can  take  place,  unless  the  tongue  of  tissue  remaining  is  de- 
stroyed by  ulceration  or  the  knife ; and  the  bleeding  will  necessarily 
continue  indefinitely.  Hence  it  is  that  wounds  of  arteries  of  this 
character  are  more  serious  than  those  in  which  they  are  cut  in  two, 
and  the  bleeding  from  them  is  more  difficult  to  stanch. 

When  an  artery  is  violently  twisted  or  torn,  there  is  usually  little 
or  no  hemorrhage,  as  its  internal  coats  are  lacerated  and  then  promptly 
retract. 

After  an  artery  has  been  secured  and  the  bleeding  arrested  until  the 
lapse  of  some  time,  and  then  the  hemorrhage  is  renewed,  it  is  said 
to  be  secondary.  It  may  occur  in  any  sort  of  wound,  and  is  most 
commonly  observed  between  the  fifth  and  twenty-fifth  days.  The 
hemorrhage  depends  upon  several  causes,  among  which  may  be  men- 
tioned sudden  movements  of  the  wounded  parts,  or  violent  muscular 


641  ON  THE  MODES  OF  ARRESTING  HEMORRHAGE. 

exertion;  ulceration  of  the  artery;  sloughing;  the  hemorrhagic  dia- 
thesis, a peculiar  condition  sometimes  observed  to  be  hereditary ; or  by 
perforation  of  the  vessel  by  a spicula  of  bone.  In  one  case  it  resulted 
from  the  excitement  of  coitus.  As  in  primary  hemorrhage,  both  ends 
of  the  artery  should  also  be  tied  in  secondary  hemorrhage. 

The  methods  that  have  been  suggested  from  time  to  time  for  arrest- 
ing hemorrhage  are  quite  numerous,  but  we  shall  only  consider  those 
that  are  actually  employed  at  the  present  day. 

1.  Styptics  are  of  two  kinds — those  acting  mechanically,  and  those 
acting  chemically ; among  the  former  are  classed,  scraped  lint,  fur, 
amadou,  spider’s  web,  and  various  absorbent  powders,  such  as  gum 
Arabic,  &c. ; among  the  chemical  styptics  we  find  the  various  astring- 
ents— tannin,  galls  ; matico ; powdered  alum,  or  a saturated  solution 
of  that  substance ; sulphates  of  iron,  copper,  and  zinc ; creasote  in 
solution ; persulphate  of  iron ; nitrate  of  silver,  and  many  others. 
The  chemical  styptics  act  by  constringing  the  tissues,  and  promoting 
the  coagulation  of  blood  ; they  can  only  be  depended  on  in  hemorrhage 
proceeding  from  the  capillaries  and  smallest  arteries. 

The  powerful  styptic  of  Pagliari  is  prepared  in  the  following  man- 
ner: Eight  ounces  of  tincture  of  benzoin,  one  pound  of  alum,  and 
ten  pounds  of  water  are  boiled  together  for  six  hours  in  a glazed 
earthen  vessel,  the  vaporized  water  being  constantly  replaced  by  hot 
water,  so  as  not  to  interrupt  the  ebullition,  and  the  resinous  mass  kept 
stirred  round.  The  fluid  is  then  filtered,  and  should  be  kept  in 
stoppered  bottles. 

The  coagulative  power  of  this  fluid  is  remarkable,  every  drop  of  it 
poured  into  a glass  containing  human  blood  produces  an  instantaneous 
magma ; and,  by  increasing  the  proportion  of  the  styptic  to  the  quan- 
tity of  blood,  a dense,  homogeneous,  blackish  mass  results. 

M.  Maisonneuve,  in  operations  attended  with  much  hemorrhage, 
uses  the  perchloride  of  iron  applied  to  each  vessel  by  a pledget  of 
charpie  which  is  allowed  to  attach  itself  to  the  wound.  The  fluid 
forms  a brown  eschar  which  separates  from  the  wound  in  from  twenty 
to  thirty  days,  leaving  a healthy  granulating  surface  beneath. 

2.  Cold. — In  bleeding  from  the  small  vessels  of  the  skin  and 
capillaries,  the  simple  exposure  of  the  wound  to  the  air  suffices  often 
to  check  it;  cold  water,  and  evaporating  solutions  applied  with  cloths 
will  be  found  more  efficient  still ; ice,  powdered  and  inclosed  in  oiled 
silk  or  a bladder,  laid  over  the  part,  is  also  a powerful  hemostatic ; or 
a lump  of  ice  may  be  put  right  upon  the  wound.  The  action  of  cold 
as  a styptic  is  similar  to  that  of  the  astringents,  and  cannot  be  relied 
upon  in  bleeding  from  large  vessels. 

3.  Actual  Cautery  acts  mechanically  in  sealing  up  the  orifices 
of  the  bloodvessels,  and  the  hemorrhage  is  liable  to  be  renewed  when 
the  eschars  separate;  the  iron  should  only  be  brought  to  a black  heat, 
so  that  it  may  also  excite  the  adhesive  inflammation  in  the  parts  as 
well  as  sear  them.  In  secondary  hemorrhage  from  a sloughing  stump, 
the  actual  cautery  will  be  found  a valuable  resort. 

4.  Pressure  is  often  employed  to  check  hemorrhage.  Sometimes 
it  is  continued  until  the  bleeding  vessels  are  firmly  sealed  up,  so  that 


ON  THE  MODES  OF  ARRESTING  HEMORRHAGE.  645 


upon  its  removal  the  blood  will  not  again  flow ; or  the  pressure  may 
be  a temporary  expedient  until  other  more  reliable  means  are  prac- 
tised to  secure  the  bloodvessel.  The  pressure  is  exercised  either  with 
the  fingers  or  with  specially  constructed  instruments  called  tourni- 
quets and  compressors.  It  is  most  efficient  and  certain  when  the  artery 
can  be  pinched  against  a solid  resisting  surface,  as  bone.  In  this 
manner  the  facial,  temporal,  and  occipital  arteries  can  be  compressed 
against  the  bone  beneath.  The  flow  of  blood  through  the  carotid 


may  be  arrested  by  making  pressure  upon  it  with  the  fingers  against 
the  cervical  vertebrae ; the  artery  is  easily  felt  at  the  inner  margin  of 
the  sterno-cleido-mastoid  muscle,  and  the  pressure  will  be  efficient 
anywhere  upon  its  course  between  the  hyoid  bone  and  the  transverse 
process  of  the  sixth  cervical  vertebra ; below  this  last  point  the 
vessel  is  too  deep  to  be  acted  upon  with  any  certainty.  It  is  re- 
markable, considering  the  anatomical  relations  of  the  carotid,  how 
long  pressure  with  the  fingers  can  be  efficiently  sustained  without 
inconveniencing  the  patient  to  any  great  extent.  The  subclavian 
artery  may  be  compressed  over  the  first  rib  either  with  the  thumb  or 
with  the  padded  ring  of  a key  placed  just  above  the  clavicle.  In  a 
case  of  a gunshot  wound  of  this  vessel,  I packed  the  wound  with 
pieces  of  sponge  until  they  projected  above  the  surface ; a compress 
was  put  on  the  sponge,  and  the  whole  dressing  sustained  by  a tourni- 
quet passing  around  the  shoulder  and  the  corresponding  elbow;  though 
this  mode  of  arresting  hemorrhage  is  very  uncertain. 

The  axillary  artery  passing  through  the  axilla  may  be  compressed 
with  the  fingers  against  the  head  of  the  humerus. 

The  brachial  is  comparatively  superficial,  and  may  be  found  run- 
ning along  the  inner  borders  of  the  coraco-brachialis  and  biceps 
muscles.  It  may  be  compressed  at  any  part  of  its  course  against  the 
humerus,  as  shown  in  Fig.  618.  The 
radial  and  ulna  arteries  may  be  easily 
felt  at  the  lower  thirds,  and  the  flow  of 
blood  arrested  in  them  by  compression 
against  the  bones  beneath.  This  plan  is 
sometimes  pursued  in  wounds  of  the 
palmar  arch,  but  is  far  from  satisfac- 
tory. In  one  case  I was  called  upon  to 
amputate  the  forearm  for  gangrene, 
where  a practitioner  had  applied  com- 
pression to  the  radial  and  ulnar  arteries 
for  palmar  hemorrhage.  In  another, 
the  bleeding  continued  in  spite  of  the 
most  persevering  compression,  to  such 
an  extent  as  to  jeopardize  the  patient’s 
life.  An  incision  was  immediately  made, 
and  the  artery  ligated.  If  compression 
is  employed  at  all  in  these  cases,  the 
best  mode  of  effecting  it  is  by  stuffing 
the  wound  in  the  palm  full  of  lint  in  the 

form  of  a giaduated  compress,  until  It  Modeofcompressingthebrachialartery  . 


Fig.  613. 


646  ON  THE  MODES  OF  ARRESTING  HEMORRHAGE. 

projects  above  the  surface.  Place  a second  compress  upon  the  back 
of  the  hand;  over  each  compress  lay  a small  stick  transversely;  then 
bind  the  extremities  of  the  sticks  together. 

In  profuse  bleeding  from  wounds 
of  the  iliac  arteries,  and  from  the 
uterus,  compression  may  be  made 
for  a short  time  upon  the  abdominal 
artery.  The  patient  should  be  placed 
horizontally,  with  his  shoulders  ele- 
vated, and  the  thighs  drawn  up  to 
relax  the  abdominal  muscles  as  much 
as  possible  in  this  position.  If  the 
person  is  moderately  thin,  the  circu- 
lation through  the  vessel  may  be 
arrested  by  pressing  it  against  the 
lumbar  vertebrae.  The  compression 
should  be  brought  to  bear  upon  a 
point  in  the  median  line  just  above 
the  umbilicus.  The  external  iliac 
artery  is  also  difficult  to  compress; 
but  it  may  be  accomplished  with  the 
fingers  by  pressing  from  before 
backwards,  and  from  within  out- 
wards, directly  over  the  linea  ilio- 
pectinea. 

With  the  thumbs  laid  one  upon 
the  other,  as  seen  in  Fig.  614,  over 
the  femoral  artery  as  it  passes  over  the  pubis,  the  current  of  blood 
through  it  may  be  at  once  controlled. 

Compression  upon  the  popliteal  artery  is  made  with  a tourniquet, 
in  the  manner  seen  in  Fig.  615,  the  vessel  being  pressed  by  the  pad 


Fig.  615. 


Fig.  614. 


Mode  of  compressing  the  femoral  artery. 


Mode  of  compressing  the  popliteal  artery  rrith  a tourniquet. 

of  that  instrument  directly  against  the  intertrochanteric  surface  of 
the  femur. 

The  posterior  and  anterior  tibia!  may  be  compressed  in  the  lower 


ON  THE  MODES  OF  ARRESTING  HEMORRHAGE.  647 

parts  of  their  courses,  the  former  behind  the  inner  malleolus,  and  the 
latter  part  upon  the  top  of  the  foot,  at  the  inner  side  of  the  tendon  of 
the  tibialis  anticus. 

In  making  pressure  with  the  hands  we  either  employ  the  thumbs 
in  the  manner  we  have  already  described,  or  the  points  of  the  fingers 
placed  close  together  in  a row.  Just  that  amount  of  force  should  be 
used  necessary  to  arrest  the  circulation,  and  no  more,  inasmuch  as 
anything  in  excess  of  this,  without  doing  any  good,  only  serves  to 
exhaust  the  person  making  the  compression.  When  one  hand  is 
tired,  the  other  may  be  substituted  for  it,  or  the  fingers  over  the 
vessel  may  be  reinforced  by  those  of  the  other  hand. 

This  mode  of  arresting  hemorrhage  with  the  fingers  is  had  recourse 
to  usually  in  emergencies,  until  other  measures  can  be  taken  to  check 
the  blood  permanently,  and  also  in  amputations  at  the  shoulder  and 
hip-joint.  In  operations  below  these  joints,  and  where  the  compres- 
sion is  required  to  be  kept  up  with  greater  certainty  and  for  a longer 
period,  tourniquets  and  compressors  are  employed.  A tourniquet 
may  be  extemporized  at  any  moment  with  a cravat,  piece  of  rope, 
strips  of  any  sort  of  cloth,  or  a bunch  of  grass,  or  fine  roots  twisted 
into  a cord.  If  required,  direct  pressure  may  be  sought  to  bear 
upon  the  bleeding  artery  by  slipping  a gravel, 
lump  of  earth,  piece  of  wood,  or  any  similar 
object  beneath  the  tourniquet. 

The  apparatus  known  under  the  name  of 
the  “Spanish  windlass”  (Fig.  616)  is  also  a 
simple  and  efficient  contrivance;  it  consists 
of  a compress  placed  over  the  artery,  and 
fixed  by  the  body  of  a cravat,  the  ends  of 
which  are  knotted  upon  the  opposite  side; 
beneath  the  knot  a piece  of  pasteboard,  or 
other  material,  is  laid,  to  prevent  the  skin 

Fig.  617. 


Field  tourniquet. 

being  painfully  pinched  when  the  cravat  is  twisted  by  the  short  stick 
introduced  under  it.  The  field  tourniquet,  now  supplied  to  the  medi- 
cal officers  of  the  army  and  navy,  consists  of  a pad  (d),  supported 
upon  the  convexity  of  a sort  of  cradle  (b)  by  the  upright  (c).  To  one 
side  of  the  cradle  the  ordinary  lac  of  webbing  (f)  is  attached,  while  the 
other  side  (g)  forms,  with  the  cross-piece  (e)  the  buckle.  From  the 
peculiarity  of  the  connections  of  the  pad,  it  holds  its  position  upon  the 
artery  remarkably  well. 


Fig.  616. 


Spanish  windlass. 


OX  THE  MODES  OF  ARRESTING  HEMORRHAGE. 


The  form  of  tourniquet  most  commonly  used  in  this  country  is  that 
of  J.  L.  Petit,  seen  in  Fig.  618.  A strong  webbing  lac  is  attached  to 

a metallic  frame  consisting  of 
two  parts,  moving  to  and  from 
each  other  by  means  of  a screw; 
the  lac  is  buckled  around  the 
limb,  and  the  required  degree 
of  constriction  is  effected  with 
the  screw.  Before  the  apparatus 
is  put  on,  it  is  important  to  see 
that  it  is  in  proper  order,  and 
that  there  is  no  chance  of  any 
of  its  parts  giving  way  during 
the  operation ; a roller  or  thick 
compress  should  be  put  over  the 
artery  beneath  the  band,  and  the 
tourniquet  placed  upon  the  op- 
posite side  of  the  limb ; or  some- 
times this  arrangement  may  be 
conveniently  reversed — that  is, 
the  tourniquet  placed  upon  the 
roller  over  the  artery. 

The  point  at  which  the  in- 
Petit’s  tourniquet.  strument  must  be  applied  will 

vary  with  the  requirements  of 
each  particular  case.  Fig.  619  shows  the  brachial  ajtery  compressed 
high  up  towards  the  axilla;  Fig.  620  presents  an  illustration  of  the 


618. 


Fig.  619. 


Fig.  620. 


Tourniquet  applied  to  the  brachial  artery. 


Tourniquet  applied  to  the  femoral  artery. 


ON  the  modes  op  arresting  hemorrhage. 


649 


Fisr.  621. 


femoral  compressed  with  the  tourniquet  just  below  Poupart’s  liga- 
ment. 

To  avoid  the  objectionable  feature  in  the  foregoing  apparatus — cir- 
cular constriction  of  the  limb — Dupuytren  devised  a compressor  which 
has  but  two  points  of  bearing,  upon  opposite  sides  of  the  limb.  It  is 
composed  of  two  curved  steel  strips  half  an  inch  broad,  sliding  upon 
each  other,  and  permitting  the  arc 
to  be  increased  or  diminished  at 
pleasure.  Each  of  the  strips  bears 
a pad  at  its  free  extremity ; one  of 
the  pads  is  movable,  the  other  fixed, 
though  both  may  be  bent  upon  the 
steel  strips  at  any  angle  by  means 
of  a joint  controlled  by  a thumb- 
screw. In  applying  the  instrument, 
the  larger  or  fixed  pad  is  placed 
upon  that  side  of  the  limb  opposite 
the  artery  upon  which  the  small  pad 
is  made  to  act  by  the  screw. 

A less  complicated  and  more  con- 
venient instrument  is  the  compressor 
of  Prof.  Gross,  of  Philadelphia,  who 
thus  describes  its  advantages  and 
construction:  “It  possesses  several 
decided  advantages  over  the  ordi- 
nary tourniquet;  first,  in  the  facility 
of  its  application ; secondly,  in  the 
amount  of  pressure  which  it  is  ca- 
pable of  exerting ; thirdly,  in  its 
ready  adaptation  to  limbs  of  differ- 
ent dimensions ; fourthly,  in  the  circumstance  that  it  makes  pressure 
only  at  two  points — that  is,  over  the  artery  and  at  the  spot  immediately 
opposite  to  the  artery ; and,  lastly,  the  facility  with  which  it  may  be 
slackened  or  removed  at  any  stage  of  the  operation.  With  a little 

Fig.  622. 


modification,  the  instrument  may  readily  be  adapted  to  the  femoral 
artery  as  it  emerges  from  beneath  Poupart’s  ligament,  or  even  to  the 


650  ON  THE  MODES  OF  ARRESTING  HEMORRHAGE. 

external  iliac  just  above  this  ligament,  in  amputation  at  the  hip-joint, 
and  also  to  the  axillary  artery,  in  disarticulation  of  the  shoulder-joint. 
By  a reference  to  the  cut,  it  will  be  seen  that  the  instrument  is  com- 
posed of  two  blades,  differing  in  the  degree  of  their  curvatures,  united 
by  a screw,  and  regulated  by  a ratchet.  Each  short  blade  is  provided 
with  a pad  capable  of  being  worked  by  a screw,  and  designed  to  rest 
upon  the  artery  which  it  is  intended  to  compress.  By  this  arrange- 
ment two  tourniquets  are  produced : a large  one  for  the  thigh,  and  a 
small  one  for  the  arm,  or  the  thigh  of  a small  subject.” 

Compression  is  occasionally  made  over  the  whole  extent  of  the 
vessel  by  compresses  laid  carefully  upon  its  course  above  the  wound, 
and  maintained  by  a roller  bandage  exercising  uniform  and  regular 
action  upon  the  limb  from  its  extremity  to  its  junction  with  the  body. 

This  method  is  useful  in  assisting  other  hemostatic  measures,  but 
should  never  be  depended  upon  alone  as  a definitive  dressing. 

Direct  pressure  upon  the  mouth  of  the  bleeding  vessels  by  plugging 
the  wounds  from  which  the  blood  issues  is  sometimes  employed,  as  in 
the  hemorrhage  following  the  operation  of  lithotomy.  When  the 
blood  issues  from  the  vessels  of  a bone,  and  other  means  fail  to  check 
it,  the  orifices  upon  the  bony  surface  may  be  plugged  with  wax  or  a 
piece  of  soft  wood;  fracture  of  the  skull  rupturing  the  middle  artery 
of  the  brain  may  require  the  same  expedient  to  arrest  the  bleeding. 

Direct  pressure  is,  however,  painful,  excites  inflammation,  and  is 
fatal  to  union  by  first  intention,  and  is  therefore  not  to  be  adopted, 
either  provisionally  or  as  an  auxiliary  to  other  hemostatic  measures 
when  the  latter  will  succeed  alone.  Generally  the  compresses  are  satu- 
rated with  some  astringent  before  their  application. 

Direct  pressure  once  established  upon  a bleeding  artery,  the  dress- 
ings should  not  be  disturbed,  as  long  as  the  hemorrhage  is  checked,  for 
seven  or  fourteen  days,  according  to  the  size  of  the  vessel. 

The  ligature  revived  by  Ambrose  Pare  as  a substitute  for  the 
cautery  iron  is  the  most  efficacious  of  all  the  hemostatic  means 
employed  by  surgeons.  It  has  been  prepared  from 
a variety  of  materials,  silk  and  linen  threads,  metallic 
wires,  especially  those  of  silver,  several  sorts  of  ani- 
mal substances,  as  catgut,  deerskin,  etc. ; but  the 
material  now  chosen  as  possessing  the  most  advan- 
tages is  well-waxed  round  silk  thread,  known  under 
the  name  of  saddler’s  silk. 

When  a thread  is  tied  around  an  artery,  it 
divides  the  inner  and  middle  coats  of  the  vessel, 
as  seen  in  Fig.  623,  leaving  the  external  cellular 
coat  included  in  the  loop.  The  blood  in  the  artery 
between  the  point  where  the  ligature  is  tied  and 
the  first  collateral  branch  above,  coagulates,  plastic 
matter  is  poured  out,  and  in  course  of  time  the  clot 
unites  Avith  the  inner  and  middle  coats,  and  finally 
this  portion  of  the  vessel  becomes  converted  into  a 
fibrous  cord.  The  ligature  by  its  pressure  causes 
ulceration  of  the  cellular  coat,  and  comes  away,  in 


Ligature  of  an  artery. 


OK  THE  MODES  OP  ARRESTIXG  HEMORRHAGE. 


651 


from  five  to  twenty-five  days,  sooner  or  later,  according  to  the  size  of 
the  artery.  We  have  stated  that  the  rounded  silk  ligature  is  generally 
chosen  because  it  makes  a clean  division  of  the  two  interior  coats  of 
the  artery;  but  in  those  cases  in  which  the  vessel  is  diseased  and 
brittle  the  ligature  must  be  larger,  and  the  knot  not  tied  so  tight, 
otherwise  it  will  cut  entirely  through.  Some  surgeons,  under  these 
circumstances,  have  preferred  to  use  flat  threads,  and  even  to  place  a 
little  compress  between  the  ligature  and  the  artery;  the  latter  plan  is 
objectionable,  and  has  justly  been  abandoned. 

When  the  bleeding  vessels  are  divided  completely,  as  in  amputation, 
their  mouths  may  be  drawn  out  a little  with  a tenaculum  or  the  points 
of  the  forceps,  the  former  instru- 
ment being  more  convenient  in 
seizing  smaller  vessels;  the  ad- 
joining nerves  and  tissues  are 
then  to  be  separated  as  far  possi- 
ble, and  the  ligatures  applied. 

Where  the  artery  lies  deep  in 
a wound,  the  ligature  is  carried 
around  it  with  the  instrument 
called  an  aneurism-needle,  which 
has  already  been  described  at 
page  43.  The  vessel  should  be 
first  laid  bare,  then  the  needle, 
armed  with  a ligature,  is  passed 
beneath  it,  and  after  its  point  has 
emerged  towards  the  orifice  of 
the  wound,  the  ligature  may  be 
seized  with  the  fingers  or  a pair 

of  forceps  and  drawn  out,  leaving  its  centre  under  the  artery.  The 
ends  of  the  thread  are  commonly  tied  with  the  sailor’s  knot,  seen  in 
Fig.  625. 


Fig.  624. 


The  surgeon’s  knot,  shown  in  Fig.  42,  is  liable  to  slip,  and  should 
not  be  used  in  the  ligation  of  arteries.  The  vessel  must  not  be 
stretched,  or  drawn  from  its  bed  in  tying 
the  knot;  this  maybe  avoided  by  holding  Fig.  625. 

the  ends  of  the  ligature  between  the  thumb 
and  last  three  fingers  of  each  hand,  while 
tfte  index  fingers  are  thrust  to  the  bottom 
of  the  wound,  and  placed  upon  each  side 
of  the  knot  to  support  it  during  the  time 
the  ligature  is  being  drawn  tight  (Fig.  624). 

Should  the  aneurism-needle  not  be  at  hand, 
the  eyed  probe  bent  at  its  extremity  may  be 
used  instead,  or  even  Belloc’s  sound,  which 
is  usually  found  in  most  all  pocket-cases. 

Where  the  blood  comes  from  an  artery  in  such  a position  that  it 
cannot  be  isolated,  the  ligature  may  be  made  to  include  the  vessel  and 
some  of  the  adjacent  tissues;  the  best  instruments  for  this  purpose  are 


652  ON  THE  MODES  OF  ARRESTING  HEMORRHAGE. 


the  tenaculum-needle,  seen  in  Fig.  626,  and  the  forceps  of  Dr.  Physick, 


shown  in  Fig.  627. 
Fig.  627. 


Fig.  626. 


Tenacalnro-needle  armed  with  a ligature. 

When  the  ligature  has  been  put  on  an  artery,  one  of 
the  threads  should  be  cut  close  to  the  knot,  and  the 
other  one  brought  out  of  the  wound  at  its  most  depend- 
ing point. 

Wounded  veins  bleeding  freely  may  also  be  ligated 
in  the  same  manner  as  an  artery;  where  a small  ori- 
fice is  simply  made  into  their  cavities  it  has  been 
vi  i recommended  to  pinch  up  the  margins  of  the  wound, 

/] and  tie  them  with  a thread,  thus  avoiding  the  oblitera- 
tion of  the  entire  calibre  of  the  vessel. 

Two  ligatures  should  always  be  put  upon  a bleed- 
ing artery  if  it  is  possible,  one  above  the  wound  and  the 
other  below;  or,  if  the  vessel  is  cut  through,  one  upon 
each  of  its  extremities.  In  other  cases,  where  it  is  im- 
practicable to  expose  the  point  of  injury,  either  through 
the  original  wound,  or  an  incision  made  for  the  pur- 
pose, there  is  but  one  course  left,  to  put  the  ligature 
upon  the  trunk  of  the  artery  above  the  wound. 

Another  plan  of  checking  hemorrhage  bv  pressure 
was  practised  by  the  ancient  surgeons,  and  in  later 
times  was  laid  aside  until  revived  by  Prof.  Simpson, 
of  Edinburgh;  we  allude  to  acupressure.  It  is  a valu- 
able addition  to  the  hemostatic  means  now  in  the  hands 
of  the  surgeon,  is  susceptible  of  varied  application,  and 
in  many  cases  possesses  advantages  over  the  ligature. 
Prof.  Pirrie,  of  Aberdeen,  thus  describes  the  prin- 
cipal methods  of  acupressure  : — 

“ The  first  method  consists  in  passing  a needle  through  the  flaps,  or 
sides  of  the  wound,  so  as  to  cross  over  and  compress  the  mouth  of  the 
bleeding  artery  or  its  tube,  just  in  the  same  way  as  in  fastening  a 
flower  in  the  lapel  of  our  coat,  we  cross  over  and  compress  the  stalk 
of  it  with  the  pin  which  fixes  it,  and  with  this  view  push  the  pin  twice 
through  the  lapel  (Fig.  628).  The  only  portion  of  the  needle  which  is 
left  exposed  internally  on  the  fresh  surface  of  the  wound  is  the  middle 
portion  of  it,  which  bridges  over  and  compresses  the  arterial  tube  at 
its  bleeding  mouth,  or  a line  or  two  or  more  in  the  cardiac  side  of  it. 
And  if  it  were  a matter  of  any  moment,  this  part  need  not  always  be 


Physick’s  artery  for- 
ceps. 


ON  THE  MODES  OF  ARRESTING  HEMORRHAGE. 


653 


left  bare,  for  the  needle  could  often  be  passed  a few  lines  higher  up, 
between  the  vessel  and  the  cut  surface,  and,  without  emerging  on  that 

Fig.  628.  Fig.  629. 


Mode  of  introducing  the  acupressure  needle. 

surface,  more  or  less  of  both  extremities  of  the  needle,  viz.,  its  head 
and  point,  are  exposed  externally  on  the  cutaneous  surface  of  the  side 
or  flap  of  the  wound. 

“ The  second  method  consists  in  entering  the  needle  on  one  side  of 
the  artery,  pushing  it  behind,  causing  its  point  to  emerge  on  the 
opposite  side  of  the  vessel,  passing  a loop  of  inelastic  iron  wire  over 
its  point,  bringing  the  wire  over  the  track  of  the  artery  and  behind 
the  stem  of  the  eye  end  of  the  needle,  drawing  it  sufficiently  to  close 
the  vessel,  and  fixing  it  by  a twist  or  half  a twist  around  the  needle. 
The  wire  with  which  the  needle  is  threaded  should  be  twisted,  that  it 
may  be  readily  distinguished.  By  means  of  this  twisted  wire  the 
needle  can  be  pulled  out,  after  which  the  loop  of  wire  is  liberated,  and 
can  be  easily  withdrawn. 

“ The  fourth  method,  or  that  by  a long  pin  and  a loop  of  passive  iron 
voire,  is  a modification  of  the  third,  and  differs  from  it  only  in  a long- 
pin,  with  a glass  head,  for  facilitating  its  insertion,  being  substituted 
for  the  common  sewing  needle  threaded  with  iron  wire.  Perhaps  of 
all  methods  the  third  and  fourth  are  the  most  secure.  The  principle 
in  each  of  these  is  the  same ; but  Prof.  Pirrie  says  he  likes  the  modifi- 
cation of  using  long  pins,  when  convenient,  from  the  form  of  the 
wound,  as  they  can  be  so  quickly  introduced,  so  readily  withdrawn, 
and  all  wriggling  and  entanglement  of  different  kinds  of  wire  with 
each  other  avoided. 

“ The  fifth  method,  or  that  by  the  twist,  may  be  varied  according  to 
the  extent  of  rotation  of  the  needle,  whether  to  a half  or  a quarter 
rotation.  The  operator  has,  on  the  cessation  of  bleeding,  a reliable 
proof  that  a sufficient 'degree  of  rotation  has  been  given  to  the  needle. 
This  method  may  be  practised  with  a long  pin  or  with  a threaded 
sewing-needle,  and  with  either  it  can  be  very  quickly  done ; but  of  all 
methods  of  acupressure  that  by  the  twist  with  a long  pin  is  the  quickest. 
In  acupressure  by  the  twist  to  the  extent  of  a half  rotation  of  the 
needle,  the  first  three  movements  given  to  the  needle  are  precisely  the 
same  as  in  the  third  method  above  described,  namely,  it  is  entered  on 
one  side,  pushed  behind  the  artery,  and  its  point  is  made  to  emerge 
on  the  opposite  side.  The  needle  is  then  twisted  over  the  artery  and 
fixed  on  the  parts  beyond.  In  this  method  the  artery  is,  to  a certain 
degree,  both  twisted  and  compressed.  Prof.  Pirrie  says  the  first  time 
he  tried  the  method  by  the  twist,  a half  rotation  was  given  to  the 


654 


ON  THE  MODES  OF  ARRESTING  HEMORRHAGE. 


needle:  but  so  little  pressure  when  direct  is  sufficient  to  arrest 
hemorrhage;  in  other  cases  a quarter  rotation  was  only  made  by  it. 

“ The  sixth  method,  or  that  by  transfixion  and  twist,  as  hitherto  tried, 
in  transfixing  the  tube  of  the  artery,  causing  the  point  of  the  needle 
to  emerge  on  the  surface  of  the  wound,  giving  a quarter  rotation  to  the 
needle,  and  fixing  its  point  in  the  tissues  beyond  the  vessel. 

“ The  seventh  method  consists  in  passing  a long  needle  through  the 
cutaneous  surface,  pretty  deep  into  the  soft  parts,  at  some  distance 
from  the  vessel  to  be  acupressed,  making  it  emerge  near  the  vessel, 
bridging  over  and  compressing  the  artery,  and  dipping  the  needle 
into  the  soft  parts  on  the  opposite  side  of  the  vessel  and  bringing  out 
the  point  of  the  needle  a second  time  through  the  common  integu- 
ment. In  this  method,  the  soft  parts  are  twice  transfixed,  and  the 
artery  is  compressed  between  the  bone  and  the  middle  portion  of  the 
needle  without  the  integument,  between  the  first  point  of  exit  and  the 
second  point  of  entrance.  Three  portions  of  the  needle  are  left  with- 
out the  integument,  namely,  its  central  portion  and  its  extremities.” 

Prof.  Pirrie  says  that  “the  first  great  point  to  be  determined  is, 
whether  or  not  acupressure  is  a perfectly  reliable  method  of  checking 
surgical  hemorrhage.  That  it  is  so,  my  belief  is  as  strong  as  it  could 
well  be  on  any  surgical  point ; and  I have  a decided  impression  that 
any  surgeon  who  gives  it  a fair  trial  will  assuredly  arrive  at  the  same 
conclusion. 

“Besides  being  as  reliable  as  any  hemostatic  yet  employed,  it 
appears  to  me  to  have  the  advantages  of  being  the  quickest,  the 
easiest  of  application,  and  the  safest  means  yet  devised  for  arresting 
bleeding.  That  the  vessels  in  a large  amputation  can  be  acupressed 
in  a much  shorter  time  than  the}''  can  be  ligatured  I am  perfectly 
satisfied ; and  in  cases  where  every  drop  of  blood  is  precious,  it  seems 
to  me  that  to  do  all  that  can  be  done  to  preserve  life,  as  far  as  saving 
of  blood  has  influence,  it  is  the  duty  of  the  surgeon  in  all  suitable 
operations  to  give  his  patient  the  benefit  of  this  new  proceeding.  But 
shortening  the  period  occupied  in  arresting  hemorrhage  is  not  only 
important  for  diminishing  one  of  the  early  dangers  of  an  operation — 
namely,  that  from  loss  of  blood — but  also  for  lessening  the  risk  of  the 
more  remote  dangers  of  suppuration,  and  many  distressing  results  of 
the  higher  grades  of  the  inflammatory  process  in  the  stump.  I have 
long  thought  we  are  too  apt  to  forget  that  living  tissues  are  resentful 
of  even  slight  injuries,  and  that  we  are  not  sufficiently  careful  to  use 
the  sponge  as  seldom,  and  as  gently  as  possible.  Whatever  shortens 
the  period  of  hemorrhage  must  diminish  the  risk  from  frequent  touch- 
ing of  the  parts.” 

Tortion,  once  lauded  as  an  efficient  hemostatic  means,  is  now  aban- 
doned except  in  its  application  to  vessels  of  the  smallest  calibre.  It 
consists  in  drawing  out  the  mouth  of  the  bleeding  vessel  with  a pair 
of  forceps  about  half  an  inch  (Fig.  630) ; a second  pair  of  forceps  is 
now  used  to  seize  the  artery  at  right  angles  to  its  axis  and  at  its  point 
of  emergence  from  the  surface,  to  hold  it  firmly  while  the  vessel  is 
being  twisted  upon  itself  by  the  first  instrument  made  to  revolve  upon 


ON  THE  DRESSINGS  OF  WOUNDS. 


655 


Fig.  630. 


Tortion  of  an  artery. 


its  axis.  In  this  manner,  by  seven  or  eight  turns  of  the  forceps,  the 
middle  and  inner  coats  of  the  artery  are  ruptured  and  twisted  in  a 
knot  which  is  to  be  returned  into  the  wound. 


CHAPTER  XVI. 

ON  THE  DRESSINGS  OF  WOUNDS. 

The  dressings  required  by  wounds  will  vary  according  to  their 
nature,  position,  and  complications ; and  it  will,  therefore,  be  conve- 
nient to  consider  them  under  the  separate  headings  of  incised,  punc- 
tured, lacerated,  contused,  and  gunshot  wounds. 

Incised  Wounds  are  solutions  of  continuity  produced  by  sharp- 
edged  instruments,  such  as  a knife,  hatchet,  or  sabre.  They  vary  in 
length  and  depth  from  the  smallest  cuts  with  the  edge  of  a penknife 
to  those  large  incisions  sometimes  following  blows  with  a sabre. 
These  wounds  may  occupy  any  part  of  the  body,  and  extend  in  any 
direction  with  its  axis — transverse,  longitudinal,  or  oblique.  The 
local  symptoms  which  characterize  them  are  hemorrhage,  pain,  and 
separation  of  the  lips  of  the  wound. 

The  hemorrhage  is  always  considerable  when  the  incision  is  of 
any  extent,  or  penetrates  to  some  depth ; the  blood  flowing  immedi- 
ately and  freely  from  the  orifices  of  the  divided  capillaries  and  arteries, 
which,  if  they  are  few  and  of  the  smallest  size,  soon  contract  upon  the 
application  of  cold  or  astringent  substances  and  cease  to  bleed  ; while, 
on  the  other  hand,  the  blood  will  gush  out  in  a copious  stream  if  the 
large  arteries  are  involved  until  the  patient  faints ; and  the  hemorrhage 
will  always  prove  fatal  unless  arrested  by  appropriate  hemostatic 
measures. 

The  pain  of  incised  wounds  results  from  the  division  of  the  nervous 
filaments  distributed  to  the  part,  and  will  vary  in  intensity  according 
to  the  position  of  the  wound,  and  the  number  of  nerve  filaments 
divided.  In  general,  those  seated  upon  the  anterior  plane  of  the  body 
are  more  painful  than  those  upon  its  posterior  plane;  and  from  the 
large  supply  of  nerves  to  the  face  and  palms  of  the  hands,  wounds  of 


656 


ON  THE  DRESSINGS  OF  WOUNDS. 


these  regions  will  also  be  very  painful.  The  condition  of  the  patient’s 
mind  at  the  time  of  the  injury  will  have  an  important  influence  upon 
the  degree  of  pain  felt.  When  a person,  for  instance,  is  sharply  en- 
gaged in  a contest,  with  all  his  energies  bent  to  the  task  of  vanquishing 
his  enemy,  he  may  have  a wound  inflicted  upon  him  and  not  feel  it, 
or  even  know  that  the  accident  has  occurred  until  he  sees  the  blood 
flow. 

The  separation  of  the  lips  of  the  wound  is  a striking  feature  of  this 
sort  of  injury,  and  it  will  take  place  in  various  degrees,  depending  on 
the  shape  of  the  instrument  that  inflicts  the  wound,  the  tension  of  the 
part  at  the  time  that  it  is  inflicted,  the  elasticity  of  the  tissues,  and  the 
amount  of  musclar  contraction.  The  first  circumstance — the  shape  of 
the  instrument  inflicting  the  injury — will  influence  the  width  of  the 
gap  by  simply  acting  mechanically,  the  weapon  serving  as  a wedge  to 
force  open  the  incision.  The  amount  of  separation  caused  in  this  way 
is  always  small,  and  in  most  cases  is  inappreciable ; so  also  is  that 
resulting  from  the  tension  of  the  part  at  the  time  the  injury  is  received ; 
for  the  moment  the  tension  is  removed,  the  edges  of  the  wound 
approximate  as  far  as  the  elasticity  of  the  tissue  and  the  muscular 
contraction  will  permit  them. 

The  purely  physical  property  of  elasticity  possessed  by  the  textures 
plays  a much  more  important  part  in  causing  wounds  to  gap  than 
those  hitherto  mentioned.  Its  influence  is  well  seen  in  incised  wounds 
of  the  skin,  which  is  the  most  elastic  portion  of  the  body;  the  margins 
of  the  incision  open  widely,  displaying  the  structures  beneath,  which, 
though  influenced  to  a certain  extent  by  their  elasticity,  are  much  less 
so  than  the  skin,  and  their  borders  do  not,  therefore,  separate  to  an 
equal  degree;  the  wound  will  in  consequence  possess  a conical  shape 
with  its  base  at  the  surface.  Muscular  contraction  excited  by  the 
wound,  also,  has  an  important  agency  in  drawing  its  lips  asunder,  and 
its  influence  is  most  marked  immediately  after  the  infliction  of  the 
injury. 

In  the  treatment  of  incised  wounds,  the  indications  are  to  remove 
all  foreign  matters  that  may  have  gained  admission  into  them  ; to  arrest 
hemorrhage,  and  to  bring  their  edges  into  accurate  contact. 

The  removal  of  foreign  bodies  may  be  accomplished  by  causing  a 
stream  of  water  to  run  over  the  wound ; any  particles  that  are  visible 
may  be  seized  and  withdrawn  with  the  forceps.  Clots  of  blood  are 
also  equally  inimical  to  union  by  first  intention,  and  should  be  care- 
fully cleared  away  from  the  wounded  surfaces. 

Hemorrhage  is  to  be  controlled  by  the  means  we  have  already 
pointed  out  in  the  previous  chapter. 

The  third  indication,  that  of  bringing  the  wounded  surfaces  together 
and  keeping  them  in  accurate  contact  until  they  may  have  united,  is 
effected  in  several  ways,  which  require  special  description. 

1.  Position. — Position  exercises  an  important  influence  in  maintain- 
ing the  edges  of  a wound  approximated.  In  all  cases,  before  recourse 
is  had  to  other  measures,  the  wounded  part  should  be  put  in  that  posi- 
tion which  permits  the  easiest  approach  of  its  margins,  and  this,  of 
course,  will  vary  with  the  situation  and  direction  of  the  wound.  If 


ON  THE  DRESSINGS  OF  WOUNDS. 


657 


the  incision  is  transverse  to  the  extensor  muscles  of  the  extremities, 
the  position  of  extension  is  required;  while  in  a similar  injury  of  the 
flexors  perfect  relaxation  is  only  to  be  attained  by  flexing  the  limb. 
In  longitudinal  wounds  of  the  extensors,  Boyer  advised  the  limb  to 
be  flexed,  and  the  reverse  in  similar  wounds  of  the  flexor  muscles ; 
but  in  this  case,  as  the  sides  of  the  wound  might  be  painfully  drawn 
upon,  it  would  be  better  to  keep  the  limb  straight,  and  the  muscles 
in  a state  of  equilibrium,  depending  rather  upon  adhesive  strips  and 
sutures  to  sustain  the  margins  of  the  wound  together. 

2.  Agglutinatives. — We  have  already  considered,  in  Part  I.,  the 
various  kinds  of  agglutinatives — adhesive  plaster,  collodion,  water- 
glass — and  the  mode  of  their  application. 

When  using  adhesive  strips  in  the  approximation  of  the  borders  of 
wounds,  the  parts  should  be  shaved  and  cleansed  before  the  applica- 
tion of  the  plaster ; the  strips  are  then  laid  over  the  wound  after  it 
has  been  drawn  together,  about  a quarter  of  an  inch  apart,  so  that  the 
blood  or  secretions  may  have  ready  egress.  The  strips  need  not  be 
changed,  as  long  as  they  serve  their  purpose,  until  cicatrization  takes 
place ; though  usually  at  the  end  of  three  or  four  days,  from  the 
quantity  of  the  discharge  from  the  wound,  from  the  plaster  loosening, 
or  from  other  causes,  their  removal  becomes  necessary.  This  must  be 
accomplished  with  care,  that  the  wound  be  not  disturbed.  The  best 
plan  is  to  seize  one  of  the  extremities  of  the  strip  in  the  fingers,  and 
detach  it  as  far  as  the  wound ; then  in  like  manner  treat  the  other 
extremity,  so  that  the  body  of  the  strip  shall  be  the  last  part  removed. 
But  one  strip  should  be  taken  off  at  a time,  and  a new  one  immediately 
substituted  for  it,  until  the  dressing  is  completed.  If,  upon  examina- 
tion, the  strips  are  found  not  to  require  changing,  the  wound  may  be 
simply  cleansed  by  allowing  warm  water  to  flow  over  it  from  a sponge 
held  just  above,  which,  combined  with  gentle  pressure,  will  suffice  to 
remove  all  the  secretions  in  and  about  it. 

M.  Chassaignac  has  derived  great  benefit  from  his  mode  of  dressing 
all  descriptions  of  wounds  by  the  prolonged  application  of  strips  of 
adhesive  plaster.  “This  plan  had  been  put  into  successful  operation  in 
respect  to  wounds  accompanying  comminutive  fractures,  large  ones 
accompanied  with  laceration  of  tendons  and  aponeuroses,  and  wounds 
resulting  from  burns,  bites  of  animals,  amputations,  and  resection,  &c. 
Since  that  period  the  same  practice  has  been  followed  by  him,  and 
with  the  following  results.  1.  The  immediate  diminution  of  the  trau- 
matic pain  in  almost  all  cases.  2.  The  absence  of  traumatic  fever  in 
the  majority.  3.  Diminution  in  the  amount  of  suppuration — an  im- 
portant point  in  the  case  of  large  burns  and  extensive  wounds.  4. 
Prevention  of  the  irritation,  and  numerous  other  inconveniences 
attendant  upon  the  daily  exposure  of  the  wound  for  the  purpose  of 
renewing  the  dressing.  5.  The  much  greater  rapidity  of  the  cica- 
trization, due  to  the  amelioration  in  the  character  of  the  suppuration, 
the  diminution  of  the  inflammation,  and  especially  the  keeping  the 
edges  of  the  wound  upon  a level  with  its  surface. 

“This  mode  of  dressing,  as  applied  by  M.  Chassaignac,  consists  in 
the  formation  of  a kind  of  cuirass  over  the  wounded  part,  by  means  of 
42 


658 


ON  THE  DRESSINGS  OF  WOUNDS. 


strips  of  adhesive  plaster  overlapping  each  other,  and  generally  dis- 
posed in  the  form  of  an  X.  This  artificial  integument  is  covered  with  a 
piece  of  rag,  perforated  with  holes,  thickly  spread  with  cerate,  and 
everywhere  extending  beyond  the  plasters.  This  rag,  covered  with 
charpie,  is  kept  in  situ  by  compresses  and  bandages.  This  dressing 
remains  on  for  eight  or  ten  days.  If  there  is  too  abundant  a suppu- 
ration, the  whole  of  the  apparatus  is  renewed,  with  the  exception  of 
the  plasters,  which  are  not  to  be  removed.  During  these  eight  or  ten 
days  the  condition  of  the  wound  thus  concealed  is  explored  by  means 
of  gentle  pressure  made  over  the  wound  through  the  cuirass,  or  along 
the  course  of  the  lymphatics,  the  bloodvessels,  the  tendinous  sheaths, 
and  the  principal  nerves.  If  inflammatory  action  is  present,  a free 
application  of  leeches,  made  either  in  the  vicinity  or  at  a distance 
from  the  wound,  suffices  to  disperse  it. 

“ The  two  objects  to  be  kept  in  view  during  the  treatment  by 
occlusion  are,  the  keeping  the  surface  of  the  wound  itself  constantly 
covered,  and  the  disposition  of  the  strapping  so  as  to  allow  the  dis- 
charge a free  escape.  But  the  surgeon  must  not  imagine  that  when 
he  has  once  applied  the  strapping,  especially  in  the  case  of  consider- 
able lesions,  as  in  compound  fractures,  the  wounds  from  operations, 
crushing  of  the  fingers,  &c.,  he  is  dispensed  from  bestowing  the  greatest 
attention  upon  the  progress  of  the  case.  Thus,  if  he  does  not  daily 
expose  the  plaster  to  view,  carefully  examine  by  gentle  pressure  the 
condition  of  the  subjacent  parts,  expel,  by  pressing  towards  the  most 
depending  parts,  all  accumulations  of  pus,  carefully  cleanse  all  parts 
of  the  cuirass  contaminated  by  the  pus,  support  by  new  strips  any 
enfeebled  part,  and  divide  any  of  those  which  seem  to  be  making 
injurious  pressure,  he  will  only  spoil  a good  measure  by  his  faulty 
application  of  it.”  {Medico  - Ohirurgical  Review,  Jan.  1860.) 

3.  Position,  aided  by  the  agglutinatives,  will  in  many  cases  secure 
the  retention  of  divided  surfaces  in  contact  most  perfectly ; where  the 
wounds  are  deeper,  in  addition  to  these,  compression  with  suitable 
bandages  will  be  required.  We  have  already  described  the  uniting 
bandages  for  transverse  and  longitudinal  wounds  at  page  212,  which, 
at  the  same  time  that  they  draw  together  their  edges,  make  more  or  less 
compression.  In  some  cases  the  object  may  be  accomplished  better  by 
placing  two  compresses  along  either  side  of  the  incision,  and  securing 
them  by  a roller  bandage  extending  from  the  toes  or  fingers  to  the 
root  of  the  limb ; in  other  instances,  immovability  and  compression 
of  the  part  may  be  secured  most  elegantly  and  efficiently  by  the 
starched  bandage,  taking  care  that  no  constriction  ensues  from  inflam- 
matory swelling. 

Sutures  are  more  often  employed  to  bring  the  margins  of  wounds 
in  contact,  when  they  are  of  greater  extent,  and  require,  besides  this 
approximation  of  their  edges,  that  the  parts  beneath  be  supported. 
The  principal  sorts  of  suture  used  by  the  surgeon  are  the  interrupted, 
continued,  twisted,  and  quilled. 

The  interrupted  suture  is  made  with  a curved  or  straight  needle, 
armed  with  a metallic  or  a well-waxed  silken  or  hempen  thread,  of  a 
thickness  proportioned  to  the  size  of  the  wound.  One  of  the  margins 


ON  THE  DRESSINGS  OF  WOUNDS. 


659 


of  the  incision  is  steadied  with  the  thumb  and  index  finger  of  the  left 
hand,  while,  with  the  right,  the  needle  is  caused  to  perforate  it  from 
without  inwards.  The  point  of  the  needle  is  again  entered  upon  the 
inner  face  of  the  opposite  margin,  and  carried  from  within  outwards  to 
pierce  the  skin  at  a distance  from  the  wound  equal  to  that  of  its  point 
of  entrance.  In  this  manner  the  required  number  of  sutures  are 
introduced  from  a half  to  three-quarters  of  an  inch  apart,  and  their 
ends  are  then  tied  with  the  reef-knot,  as  seen  in  Fig.  631,  without, 
however,  constricting  the  tissue  inclosed  in  the  loop ; the  knots  should 
be  upon  the  side  of  the  incision,  and  not  over  it,  as  shown  in  the  figure. 
In  superficial  wounds,  the  threads  should  not  pass  through  the  fibrous 
or  muscular  tissues;  while,  in  other  cases,  their  depth  must  be  such  as 
to  secure  the  closest  approximation  of  the  wound.  The  distance  at 

Fig.  631.  Fig.  632. 


The  interrupted  suture.  The  continuous,  or  Glover’s  suture. 

which  the  needle  is  entered  from  the  incision 
will  also  vary  with  its  extent,  from  two  or  three 
lines  to  a quarter  of  an  inch. 

The  continuous  suture  is  executed,  as  in  the 
previous  instance,  with  a needle  and  thread. 

The  needle  is  pressed  obliquely  through  both 
margins  of  the  wound,  its  point  entering  upon 
the  same  side  at  every  stitch,  so  that  the  thread 
describes  a spiral  between  the  extremities  of 
the  incision.  This  suture  is  principally  em- 
ployed in  wounds  of  the  intestines  and  abdo- 
men (Fig.  632). 

The  twisted  suture  requires  pins  or  straight 
needles,  with  spear  points,  such  as  are  seen  in 
Figs.  633  and  634 ; the  former  being  the  old 
form  of  needle  used  in  hare-lip,  and  the  latter 
the  new  and  improved  one.  The  best  material 
of  which  to  prepare  these  needles  is  gold,  as  it 
does  not  become  oxidized  and  irritate  the  parts, 
or  adhere  to  them  when  incrusted  with  dried 
blood  or  pus.  The  needles  most  commonly  em- 


Fig.  633.  Fig.  634. 


Needles  for  twisted  sutures. 


660 


ON  THE  DRESSINGS  OF  WOUNDS. 


ployed,  however,  are  those  made  of  steel,  of  the  shape  seen  in  Fig.  634. 
The  suture  is  made  in  this  manner : The  lips  of  the  wound  are  held 
in  accurate  contact,  and  then  the  needle  or  pin  held  in  the  fingers  or 
forceps  is  passed  through  them  both,  at  that  point  first  where  it  is  most 
important  to  obtain  union;  then,  in  succession,  other  needles  are  intro- 
duced in  like  manner  at  convenient  distances  until  a sufficient  number 
has  been  used.  The  surgeon  now  takes  a piece  of  thread  in  both  hands 
and  entwines  its  loop  around  the  first  pin  in  the  form  of  an  ellipse,  or, 
what  is  more  common,  in  the  form  of  a figure  of  8 (Fig.  635).  The 
threads  are  then  crossed  over  the  intervening  space,  and  a figure  of  8 
made  upon  the  second  pin,  and  so  on  until  they  are  all  encircled  with  the 
threads.  The  points  of  the  pins  must  then  be  cut  off  with  the  pliers 
(Fig.  636),  that  they  may  not  wound  the  patient,  or  catch  in  the  clothes. 

Fig.  635.  Fig.  636. 


Twisted  or  hare-lip  suture. 


At  the  end  of  three  or  four  days,  or  earlier,  according  to  the  cir- 
cumstances of  the  case,  when  the  suture  is  to  be  removed,  the  pins 
are  to  be  seized  by  their  heads  with  a pair  of  forceps  and  drawn  out, 
while  the  thread  is  supported  by  the  point  of  the  left  index  finger. 
The  thread  either  falls  at  the  same  time,  or,  what  is  more  common, 
remains  sticking  to  the  skin  two  or  three  days  longer. 

A very  elegant  modification  of  the  twisted  suture  has  been  recently 


Fig.  637. 


India-rubber  suture. 


Fig.  638. 


ON  THE  DKESSINGS  OF  WOUNDS. 


661 


introduced  into  practice  by  M.  Gariel,  consisting  in  the  substitution 
of  little  India-rubber  rings  for  the  threads,  and  applied  as  seen  in 
Fig.  637.  The  rings  are  obtained  from  sections  of  India-rubber  tubes 
of  any  desired  size. 

The  quilled  suture  (Fig.  638)  is  made  by  passing  through  the  edges  of 
the  wound  a number  of  double  threads  at  intervals  of  about  an  inch, 
with  a curved  needle — or,  better,  with  the  tenaculum-needle.  A quill, 
piece  of  bougie,  or  a slender  stem  of  wood  is  put  under  the  loops 
formed  by  the  threads  upon  one  side  of  the  wound ; the  extremities 
of  the  threads  are  then  separated,  and  a piece  of  bougie  placed  be- 
tween them,  over  which  they  are  to  be  tied  sufficiently  firm  to  hold 
the  margins  of  the  wound  in  contact. 

In  removing  this  suture,  which  is  principally  used  in  rupture  of 
the  perineum,  it  suffices  to  cut  the  loops,  when  the  threads  may  be 
readily  withdrawn. 

What  is  called  the  dry  suture,  consists  in  fastening  along  the  mar- 
gins of  a wound  two  narrow  strips  of  adhesive  plaster,  and  then 
sewing  their  contiguous  margins  together. 

There  are  other  forms  of  suture  used  in  special  cases — such  as  the 
tongue  and  groove  suture  of  Prof.  Pancoast;  the  button  suture  of  Dr. 
Bozeman,  and  the  clamp  suture  of  Dr.  Sims,  a description  of  which 
does  not  fall  within  our  limits. 

M.  Vidal  has  invented  an  ingenious  little  instrument  for  maintain- 
ing  the  edges  of  a wound  together,  and  for  which  he 
was  awarded  a prize  by  the  Institute  of  France.  It  Fig.  639. 
is  made  of  fine  silver  wire,  bent  in  the  form  seen  in 
Fig.  639.  The  points  are  toothed  so  that  they  will 
take  firm  hold  upon  the  margins  of  the  incision,  and 
sustain  them  in  contact  by  the  spring  of  the  wire. 

The  instrument  acts  very  superficially,  and  cannot 
be  used  in  wounds  of  any  depth. 

Under  the  most  favorable  circumstances,  when  the  edges  of  incised 
wounds  have  been  brought  into  exact  apposition,  their  union  may 
take  place  by  immediate  adhesion,  that  is,  no  inflammation  will  be  de- 
veloped, or  effusion  of  plastic  matter  occur;  but  the  continuity  of  the 
fibres,  bloodvessels,  and  nerves  will  be  immediately  re-established,  and 
no  cicatrix  will  remain. 

Another  mode  of  healing,  sometimes  observed,  is  that  called  by 
McCartney  the  “ modelling  process ;”  it  consists  in  the  breach  in  the 
tissues  being  repaired,  without  inflammation,  under  a covering  or  scab 
formed  by  the  concretion  of  blood  or  the  secretions  of  the  part ; or, 
an  artificial  crust  may  be  formed  with  gum  Arabic  or  any  other  bland 
absorbent  powder. 

Union  may  be  effected  in  a third  mode,  or  by  adhesive  inflamma- 
tion ; the  margins  of  the  wound  become  moderately  inflamed  and 
swell  a few  hours  after  the  injury,  and  a reddish  plastic  fluid  is  effused 
between  them,  which  is  promptly  organized  into  a bond  of  union. 

Should  the  degree  of  inflammation  surpass  that  required  for  the 
formation  and  organization  of  the  effused  plasma,  the  surfaces  of  the 
wound  become  covered  with  a yellowish-white  vascular  membrane 


662 


ON"  THE  DRESSINGS  OF  WOUNDS. 


studded  with  small  projecting  points  called  granulations,  which  are 
enveloped  with  pus. 

If  now  these  granulations  are  kept  in  accurate  apposition,  they 
may  unite,  constituting  what  is  called  union  by  second  intention. 
When  the  granulating  surfaces  are  not  brought  together,  but  left 
exposed  to  the  air,  the  membrane  covering  them  acquires  increased 
thickness,  and  contracts,  drawing  their  margins  towards  the  centre  of 
the  wound,  while  the  granulations  now  level  with  the  surface  become 
smaller,  and  those  at  the  circumference  of  the  wound  covered  with  a 
thin  bluish  pellicle  which  gradually  extends  towards  the  centre  until 
the  whole  surface  is  covered  with  a cellulo-fibrous  membrane  called 
a cicatrix. 

B.  Contused  Wounds  are  produced  by  blunt  weapons,  such  as  a 
club,  by  the  passage  of  a wheel  over  the  body,  or  by  gunshot;  the 
parts  are  torn  or  bruised  in  various  degrees  from  the  mere  laceration 
of  the  skin  and  a few  small  bloodvessels  to  the  complete  disorganiza- 
tion of  muscles,  bloodvessels,  and  bones.  In  the  latter  case,  there  is 
always  great  shock  inflicted  upon  the  system ; the  patient  is  prostrated 
with  a feeble  pulse,  bleached  skin,  and  cold  extremities,  and  when 
reaction  set  in,  will  frequently  vomit. 

From  the  damage  done  to  the  nerves  there  will  generallv  be  con- 
siderable pain  felt  unless  the  parts  are  disorganized,  when  it  may  not 
be  present  at  all ; the  bloodvessels  being  bruised,  the  blood  will 
speedily  coagulate  in  them  and  prevent  hemorrhage. 

The  margins  of  the  wound  are  generally  irregular,  torn,  and  infil- 
trated with  blood. 

When  the  injury  is  inflicted  without  breaking  the  skin,  it  is  called 
a contusion,  in  which  the  smaller  vessels  only  may  be  torn,  giving 
rise  to  an  infiltration  of  blood  beneath  the  skin,  or  ecchymosis ; or 
larger  arteries  will  sometimes  be  involved  and  the  blood  escape  in 
greater  or  less  quantity  so  as  to  form  collections  of  different  magni- 
tudes, from  the  size  of  a small  nut  to  that  of  an  infant’s  head,  or  even 
larger. 

In  the  treatment  of  contusions  the  object  will  be  to  check  inflam- 
mation, and  subsequently  to  promote  the  absorption  of  the  effused 
blood.  The  first  indication  is  fulfilled  by  the  application  of  leeches, 
cold  water-dressings,  solutions  of  the  acetate  of  lead  and  opium,  or  a 
mixture  of  alcohol  and  water;  and  the  second  by  stimulating  infric- 
tions of  camphorated  alcohol,  tincture  of  arnica,  or  such  like  sub- 
stances. Under  this  treatment  the  ecchymosis  will  usually  disappear 
in  a few  days ; large  collections  of  blood  may  be  removed  by  a small 
incision  through  the  skin.  In  contused  wounds,  such  of  the  lacerated 
parts  as  possess  vitality  should  be  thoroughly  cleansed  and  brought 
together  by  suture  and  adhesive  strips.  If  there  is  any  hemorrhage, 
it  must  be  suppressed  by  the  means  we  have  already  pointed  out. 
Inflammation  must  be  kept  down  by  the  use  of  cold  applications : or, 
when  pretty  active,  leeches  ma}r  be  had  recourse  to.  During  the  time 
that  the  sloughs  are  separating,  secondary  hemorrhage  may  occur, 
and  should  be  met  by  appropriate  measures. 

C.  Punctured  Wounds.— These  wounds  are  inflicted  by  such  in- 


ON  THE  DRESSINGS  OF  WOUNDS. 


663 


struments  as  the  sword,  bayonet,  lance,  knife,  nails,  splinters  of  wood, 
or  any  other  sharp-pointed  and  hard  body.  If  these  instruments  are 
slender,  well  polished,  and  sharp,  they  penetrate  the  body  by  sepa- 
rating the  fibres  of  the  tissues,  and  there  will  be  little  or  no  lacera- 
tion; while  other  objects  that  are  rough,  thick,  or  blunt,  will  produce 
more  or  less  contusion  in  tearing  their  course  through  the  soft  parts. 

Punctured  wounds  will  vary  much  in  character,  according  to  their 
position,  extent,  and  the  nature  of  the  instrument  with  which  they 
have  been  inflicted. 

The  pain  which  accompanies  them  is  most  generally  very  severe, 
especially  when  they  are  produced  by  some  rough  object,  and  occupy 
a position  among  the  fasciae,  or  parts  abundantly  supplied  with  nerves. 
There  is  rarely  any  amount  of  blood  observed  to  flow  from  the  punc- 
ture, and  should  a large  artery  be  perforated,  the  hemorrhage  will 
occur  in  the  surrounding  tissues,  forming  traumatic  aneurism. 

This  variety  of  wound  is  the  one  most  often  followed  by  such  com- 
plications as  abscess,  tetanus,  erysipelas,  &c. 

The  indications  of  treatment  in  punctured  wounds  are  to  remove 
all  foreign  bodies  from  them  with  the  fingers  or  forceps,  assisted,  if 
necessary,  by  appropriate  incisions ; to  check  hemorrhage  by  the 
application  of  compressors,  ligature,  or  other  hemostatic  means ; and 
to  control  inflammatory  action  by  the  use  of  local  antiphlogistics. 

D.  Gunshot  Wounds. — Gunshot  injuries  are  contused  and  lacerated 
wounds  produced  by  the  explosion  of  fire-arms,  as  pistols,  rifles,  can- 
non, &c.  They  are  of  different  degrees  of  gravity,  according  to  their 
extent,  location,  and  the  character  of  the  projectile  by  which  they 
have  been  occasioned.  In  most  cases  there  will  be  more  or  less  shock 
produced  by  the  injury.  The  pain  is  not  great  as  a general  rule : and 
I have  seen  a number  of  instances  in  which  the  limb  was  perforated 
by  a Minie  ball  and  the  bone  shattered,  yet  there  was  no  pain : the 
patient  complained  only  of  a feeling  of  weight  in  the  part  as  long  as 
it  remained  quiet.  Lulled  into  a sense  of  false  security  by  this  absence 
of  pain,  patients  have  often  become  the  victims  of  their  own  impru- 
dence, in  their  great  anxiety  to  save  their  limbs,  by  declining  surgical 
interference  at  the  opportune  moment ; and  not  until  the  lapse  of  three 
or  four  days,  when  inflammatory  action  has  set  in  and  the  limb  becomes 
swollen  and  painful,  do  they  feel  the  futility  of  their  hopes  and  the 
rashness  of  their  conduct. 

The  hemorrhage  from  gunshot  wounds  is  usually  small;  sometimes, 
however,  a large  artery  may  be  divided  by  a ball  moving  with  great 
velocity,  and  copious  bleeding  follow.  What  the  surgeon  has  most 
to  fear  in  this  respect  is  secondary  hemorrhage,  which  generally  takes 
place  between  the  fifth  and  twenty-fifth  days.  In  either  case  the  im- 
perative rule  is  to  ligate  both  extremities  of  the  artery,  should  it  be 
possible ; if  not,  put  the  ligature  upon  the  trunk  above  the  wound. 

The  injury  should  be  examined  as  soon  as  practicable  after  its  in- 
fliction, and  all  foreign  bodies  removed  from  it,  such  as  bullets,  pieces 
of  clothing,  fragments  of  shell,  &c.  The  best  probe,  if  it  can  be  used, 
is  the  finger,  which  should  be  gently  introduced,  and  all  parts  of  the 
wound  fully  explored  with  it;  in  other  cases  a stout  probe  (Fig.  27, 


664 


ON  THE  DRESSINGS  OF  WOUNDS. 


p.  41),  eight  or  ten  inches  long,  may  be  employed  to  penetrate  to 
greater  depths  than  can  be  reached  with  the  finger ; a straight  silver 
catheter  may  be  used  for  the  same  purpose.  If  a leaden  object  is 
present,  a very  ingenious  method  of  detecting  it  is  with  Nekton's 
probe,  which  is  simply  a long  metallic  stem  tipped  with  a little  ball 
of  unglazed  porcelain ; the  slightest  contact  of  the  ball  with  the  metal 
will  produce  a black  stain.  MM.  Fontan  and  Favre  recommended  for 
the  detection  of  metallic  objects  an  explorer  composed  of  two  insulated 
wires  connected  with  a single  cup  of  Smee’s  battery ; the  explorer 
coming  in  contact  with  the  metal,  establishes  a galvanic  current,  which 
is  indicated  by  the  deflexion  of  a galvanometer  attached  to  the  appa- 
ratus. The  plan  is  ingenious,  but  entirely  destitute  of  practical  utility. 

For  withdrawing  bullets  and  other  objects,  the  most  useful  instru- 
ment will  be  a pair  of  long,  slender-bladed  forceps,  such  as  are  seen 
in  Fig.  640.  Should  the  body  be  felt  beneath  the  skin,  an  incision 


Fig.  640. 


Fig.  641. 


Kolb^'s  bullet-forceps. 


must  be  made  upon  it,  and  the  body  turned  out  of  its  bed  with  the 
finger  or  forceps;  the  rule  to  follow,  in  such  cases,  being  to  remove 


ANAESTHESIA. 


665 


all  foreign  matter  from  that  point  of  the  surface  to  which  they  are 
nearest.  The  bullet-forceps  of  Mr.  Kolbe,  a skilful  instrument-maker 
of  Philadelphia,  may  also  be  employed  to  remove  bullets.  It  consists, 
as  shown  in  Fig.  641,  of  a metallic  tube  with  two  short  serrated  jaws 
articulated  with  one  of  its  extremities,  and  capable  of  being  expanded 
or  closed  by  turning  a screw  placed  at  the  other.  The  instrument  is 
introduced  closed,  and  may  be  used  as  a probe ; 
when  the  bullet  is  felt,  it  is  at  once  grasped  by 
opening  the  jaws  of  the  forceps. 

The  instrument  sketched  in  Fig.  642  has  a 
movable  point,  which  may  be  bent  by  the  stem 
running  through  the  tube,  at  a right  angle  with 
the  latter.  The  extractor  is  introduced  into  the 
wound  beyond  the  object,  when  its  point  is  thrown 
down,  as  seen  in  the  figure.  The  inner  surface 
of  the  point  is  concave,  to  embrace  the  ball. 

When  the  missile  is  buried  in  the  bone,  it 
may  require  the  use  of  the  trephine  or  gouge  to 
remove  a sufficiency  of  it  adjoining  the  ball  to 
allow  the  forceps  to  get  a good  hold  upon  the  latter.  The  sharp- 
pointed  screw,  so  much  employed  in  former  times  for  extracting  balls, 
is  now  justly  abandoned. 

After  the  foreign  bodies  have  been  removed  and  the  wound  tho- 
roughly cleansed,  its  sides  must  be  supported  with  adhesive  plaster, 
or  compresses  and  a roller  bandage.  To  control  subsequent  inflam- 
matory action,  cold  water-dressings  will  generally  be  found  most 
agreeable;  and  should  sloughing  impend,  they  must  at  once  be  aban- 
doned for  warm  applications.  When  there  is  any  burrowing  of  pus, 
free  incisions  should  be  made  to  evacuate  it. 


Fig.  642. 


Bullet-extractor. 


CHAPTER  XVII. 

ANAESTHESIA. 

The  minds  of  surgeons  had  been  from  a remote  period  engaged  in 
fruitless  efforts  to  discover  some  means  of  preventing  pain  during  sur- 
gical operation ; but  it  was  not  until  the  year  1847  that  success 
crowned  their  exertions.  This  desideratum  must  have  been  felt  by  the 
older  surgeons,  previous  to  the  revival  of  the  ligature  as  a hemos- 
tatic agent  by  Ambrose  Pard,  much  more  severely  than  since  that 
period;  for  to  check  a hemorrhage,  now  controlled  by  a single  thread, 
the  only  means  in  their  possession  were  the  red-hot  knife,  or  the  searing 
cautery ; and  sometimes  bleeding  stumps  were  thrust  into  pots  of  boiling 
pitch.  Such  means  might  well  cause  the  most  resolute  and  enduring 
to  recoil  from  the  severities  of  a surgical  procedure,  especially  when 
nothing  beyond  the  temporary  numbing  of  the  sensibilities  by  opium 
or  other  narcotic  could  be  obtained. 


666 


ANESTHESIA. 


Local  Anesthesia. — The  methods  that  have  been  employed  to 
produce  local  anaesthesia  at  different  periods  may  be  considered  under 
three  heads : Compression,  local  narcotization,  and  refrigeration. 

Compression  has  been  made  in  two  ways,  either  directly  upon  the 
part  to  be  incised,  or  upon  the  trunk  of  the  nerve  leading  from  the 
limb.  In  the  first  instance  we  see  an  illustration  of  the  numbing  in- 
fluence of  pressure  in  the  anaesthetic  effect  of  pinching  the  edges  of  a 
wound  between  the  fingers  before  passing  the  needle  through  them  in 
making  a suture.  Compression  upon  the  trunk  of  the  nerve  was  par- 
ticularly brought  forward  by  Mr.  John  Moore,  of  London,  who  invented 
an  instrument  for  the  purpose  analogous  to  the  compressor  of  Dupuy- 
tren  already  described ; one  of  the  pads  of  the  instrument  was  placed 
over  the  sciatic,  and  the  other  over  the  crural  nerve : several  opera- 
tions were  performed  upon  the  lower  extremity,  while  the  apparatus 
was  applied,  but  anaesthesia  was  so  imperfectly  attained  that  that  plan 
was  soon  abandoned. 

Local  narcotization  was  long  ago  practised  for  the  object  of  annihi- 
lating pain  during  operations.  M.  Bouisson  states  that  he  applied  a 
plaster  of  opium  to  the  toe  of  a patient  for  some  time,  and  afterwards 
succeeded  in  partially  tearing  away  the  nail  without  causing  pain;  he 
was  also  in  the  habit  of  using  belladonna  ointment  to  relieve  the  pain 
of  the  operation  for  fissured  anus.  A plan  was  pursued  some  years 
ago  of  smearing  bougies,  catheters,  etc.  with  narcotic  ointments,  while 
dilating,  cauterizing,  or  incising  stricture  of  the  urethra. 

Refrigeration  may  be  produced  in  several  ways.  The  old  plan 
was  to  apply  to  the  parts  demanding  surgical  interference,  various 
frigorific  mixtures,  usually  ice  and  one  of  the  salts  of  sodium  or  potas- 
sium; equal  parts  of  pounded  ice  and  common  salt  is  as  good  a mix- 
ture as  any  other  for  this  purpose.  Its  anaesthetic  effects  are  restricted 
to  the  skin  and  cellular  tissue,  and  will  not,  therefore,  be  available  in 
operations  requiring  the  incision  to  go  deeper  than  those  structures. 
I have  used  it  in  opening  buboes,  abscesses,  and  in  superficial  inci- 
sions with  success. 

A simple  apparatus  is  required  in  applying  the  ice  mixture;  a pig's 
bladder,  or  a piece  of  oiled  silk;  the  temperature  must  be  brought 
below  32°  Fahr.,  perhaps  between  15°  and  25°  will  be  as  safe,  which 
will  produce  the  requisite  degree  of  anaesthesia  in  from  fifteen  to  twenty 
minutes. 

This  method  may  be  employed  where  the  apparatus  of  Mr.  B.  TV. 
Richardson  is  not  at  hand,  and  it  will  answer  very  well  in  the  class  of 
cases  above  mentioned. 

The  ingenious  contrivance  of  this  gentleman  leaves  little  to  be 
desired  for  the  convenient  and  efficient  application  of  cold  in  the  pro- 
duction of  local  anaesthesia.  The  apparatus  which  he  originally 
devised  consisted  “ simply  of  a graduated  bottle  for  holding  ether ; 
through  a perforated  cork  a double  tube  is  inserted,  one  extremity  of 
the  inner  part  of  which  goes  to  the  bottom  of  the  bottle.  Above  the 
cork  a little  tube  connected  with  a hand  bellows  pierces  the  outer  part 
of  the  double  tube,  and  communicates  by  means  of  the  outer  part  by 
a small  aperture  with  the  interior  of  the  bottle.  The  inner  tube  for 


ANAESTHESIA.. 


667 


delivering  the  ether  runs  upwards  nearly  to  the  extremity  of  the  outer 
tube.  Now,  when  the  bellows  are  worked,  a double  current  of  air  is 
produced,  one  current  descending  and  pressing  upon  the  ether,  forcing 
it  along  the  inner  tube,  and  the  other  ascending  through  the  outer 
tube,  and  playing  upon  the  column  of  ether  as  it  escapes  through  the 
fine  jet.” 

This  instrument  has  been  further  improved  by  substituting  for  the 
bellows  two  India-rubber  balls,  which  render  it  more  convenient  and 
portable,  without  destroying  the  efficiency  of  its  action. 

“ By  this  simple  apparatus,  at  any  temperature  of  the  day,  and 
at  any  season,  the  surgeon  has  thus  in  his  hands  a means  for  pro- 
ducing cold  even  6°  below  zero ; and  by  directing  the  spray  upon  a 
half-inch  test-tube  containing  water  he  can  produce  a column  of  ice  in 
two  minutes  at  most.  Further,  by  this  modification  of  Siegle’s  appa- 
ratus he  can  distribute  fluids  in  the  form  of  spray  into  any  of  the 
cavities  of  the  body — into  the  bladder,  for  instance,  by  means  of  a 
spray-catheter,  or  into  the  uterus  by  a uterine  spray-catheter.” 

“ When  the  ether  spray  thus  produced  is  directed  upon  the  outer 
skin,  the  skin  is  rendered  insensible  within  a minute ; but  the  effects 
do  not  end  here.  So  soon  as  the  skin  is  divided,  the  ether  begins  to 
exert  on  the  nervous  filaments  the  double  action  of  cold  and  of  ether- 
ization ; so  that  the  narcotism  can  be  extended  deeply  to  any  desired 
extent.  Pure  rectified  ether  used  in  this  manner  is  entirely  negative; 
it  causes  no  irritation,  and  may  be  applied  to  a deep  wound,  without 
any  danger.  I have  applied  it  direct  to  the  mucous  membrane  of  my 
own  eye,  after  first  chilling  the  ball  with  the  lid  closed.” 

Reaction  from  the  anaesthesia  is  in  no  degree  painful,  and  hemor- 
rhage is  almost  entirely  controlled  during  the  anaesthesia. 

One  or  two  precautions  are  necessary.  It  is  essential,  in  the  first 
place,  to  use  pure  rectified  ether;  methylated  ether  causes  irritation, 
and  chloroform,  unless  largely  diluted  with  ether — say,  one  part  in 
eight — does  the  same. 

General  Anaesthesia. — Various  plans  have  been  suggested  and 
tried  from  an  early  period  in  the  history  of  surgery,  to  render  patients 
insensible  during  the  performance  of  surgical  operations.  The  ancients 
used  the  root  of  the  mandrake  steeped  in  wine;  Theodoric,  in  the 
thirteenth  century,  recommended  the  inhalation  of  opium,  and  in  1538 
we  find  Ganappe  imitating  Theodoric  in  using  narcotics  by  inhalation 
for  the  same  purpose. 

Sir  Humphry  Davy,  in  1799,  remarked  that  “as  nitrous  oxide,  in 
its  extensive  operation,  appears  capable  of  destroying  physical  pain, 
it  may  probably  be  used  with  advantage  in  surgical  operations.” 

In  1844,  Dr.  Horace  Wells  employed  the  nitrous  oxide  in  his  own 
case,  having  a tooth  extracted  painlessly ; he  afterwards  gave  it  to 
several  patients  upon  whom  a similar  operation  was  performed,  with 
the  most  gratifying  success. 

Mesmerism  was  practised  by  Dr.  Esdaile,  a surgeon  in  India,  and 
he  states  that  he  had  submitted  patients  under  its  influence  to  the 
larger  operations  without  causing  them  the  slightest  pain. 

Hypnotism,  a name  given  by  Mr.  Braid  to  a sort  of  somnambulic 


668 


ANAESTHESIA. 


sleep  produced  by  intently  gazing  at  a bright  object,  has  also  been 
had  recourse  to  for  the  purpose  of  producing  anaesthesia. 

Both  of  these  processes  are  uncertain  in  their  operation  and  of  little 
or  no  practical  use  to  the  surgeon. 

Ether  was  first  used  as  an  anaesthetic  by  Dr.  Morton,  a dentist  of 
Boston,  in  1884,  for  the  purpose  of  preventing  pain  during  the  ex- 
traction of  teeth. 

He  afterwards  etherized  two  patients  undergoing  surgical  operations, 
one  for  Dr.  J.  C.  Warren  and  the  other  for  Dr.  Haywood. 

Since  that  time  it  has  been  employed  in  every  portion  of  the  civilized 
world,  and,  mixed  with  chloroform — usually  three  parts  of  the  former 
to  one  of  the  latter — is  generally  preferred  for  anaesthetic  purposes 
by  American  surgeons.  Some,  however,  still  give  the  preference  to 
chloroform,  and  during  the  late  war  it  was  more  commonly  used  than 
ether  by  the  military  surgeons,  and  given  in  thousands  of  cases  with 
the  most  gratifying  results. 

I have  used  it  in  many  cases,  and  never  saw  any  bad  effects  follow. 
In  those  patients,  even,  who  had  suffered  severe  shock  chloroform 
was  often  employed  as  a stimulant  along  with  brandy,  and  where  im- 
mediate operations  were  required  no  unnecessary  time  was  lost  from 
any  fear  that  its  administration  would  add  to  the  depression  already 
present  from  the  injury. 

Up  to  the  present  time  there  have  been  but  few  instances  of  death 
following  the  use  of  ether,  while  chloroform  reckons  among  its  victims 
some  hundred  or  more.  Various  reasons  have  been  assigned  for  this 
difference.  The  fact  that  chloroform  is  more  energetic  than  ether  is 
undoubted,  and  that  it  requires  greater  care  in  its  administration  to 
insure  security  from  accident  is  also  certain ; and,  lastly,  it  has  been 
observed  that  it  may  undergo  changes  by  exposure  to  light  and  heat, 
so  that  poisonous  compounds  are  developed  by  the  chemical  reactions 
following. 

To  a want  of  proper  attention  to  the  first  point  mentioned,  at  the 
introduction  of  chloroform  into  surgical  practice,  may  be  attributed 
some  of  the  fatal  cases.  Too  large  a quantity  of  the  agent  being  used 
without  due  regard  being  paid  to  the  admission  of  air.  Other  cases 
resulted  from  syncope,  by  giving  the  chloroform  while  the  patient 
was  in  an  erect  posture,  thus  opposing  to  the  action  of  an  already 
enfeebled  heart,  the  retarding  influence  of  gravity.  Under  this  head, 
perhaps,  fall  the  unfortunate  cases  (which  are  by  no  means  an  incon- 
siderable portion  of  the  whole  number)  of  the  dentists. 

As  to  the  third  point — chemical  changes  in  the  chloroform  pro- 
ducing poisonous  compounds — it  is  recorded  that  this  anassthetic  was 
given  during  the  Crimean  War  in  12,000  cases,  with  but  one  death 
resulting  from  the  agent,  and  in  this  instance  the  chloroform  used  was 
in  a forward  state  of  decomposition ; from  the  want  of  any  other  evi- 
dence of  the  cause  of  the  fatal  termination,  death  was  attributed  to 
the  poisonous  compounds  developed  by  these  chemical  changes. 

Latterly  we  hear  unfrequently  of  fatal  cases  from  the  use  of  chloro- 
form, and  this  infrequency  will  amount  to  total  immunity  when  the 
importance  of  the  three  foregoing  facts  is  fully  recognized  and 


ANESTHESIA. 


669 


properly  attended  to.  In  other  words,  chloroform  in  proper  quantity, 
of  good  quality,  and  carefully  administered,  may  be  as  safely  used  in 
operative  surgery  as  ether. 

That  chloroform  will  ever  be  supplanted  by  any  anaesthetic  yet 
discovered  is  quite  improbable ; and  the  success  which  has  attended 
its  employment  in  thousands  of  cases  of  surgical  operations,  during 
the  war  of  the  rebellion,  has  given  the  uprising  generation  of  surgeons 
a confidence  in  the  value  of  this  agent  that  must  remain  unshaken. 

Mr.  Arnott,  of  London,  the  champion  of  local  anaesthesia,  has 
endeavored  to  prove,  by  statistics,  that  since  the  introduction  of  the 
anaesthetics  the  mortality  after  surgical  operations  has  been  materially 
increased.  But  all  statistics  drawn  from  a comparison  of  total  operations 
of  all  classes  before  and  after  the  employment  of  these  agents  will  not 
fairly  settle  the  question  of  the  relative  mortality,  inasmuch  as  with 
the  anaesthetics,  surgeons  have  been  enabled  to  bring  within  the  limits 
of  application  of  the  knife  a large  number  of  operations  that  had 
hitherto  been  rarely,  or  not  at  all,  attempted,  and  among  which  there 
was  necessarily  a large  number  of  fatal  cases. 

The  only  proper  method  would  be  to  compare  the  same  classes  of 
operations  with  each  other  performed  before  and  since  the  discovery 
and  use  of  the  anaesthetics ; that  is,  amputations  with  amputations, 
lithotomy  with  lithotomy,  &c. 

It  is  my  opinion,  based  upon  the  observations  of  numerous  cases 
during  the  war,  that  the  use  of  chloroform  improved  the  chances  of 
recovery  by  diminishing  the  shock  of  the  operation  and  giving  the 
surgeon  another  advantage  of  no  mean  value,  namely,  complete  control 
over  the  patient  so  that  he  may  proceed  with  his  incisions  with 
accuracy,  certainty,  and  a reasonable  amount  of  leisure. 

It  has  been  stated  that  chloroform  changes  the  character  of  the 
blood  and  diminishes  the  tone  of  the  capillaries,  thereby  giving  rise 
to  a greater  frequency  of  secondary  hemorrhage  after  operations. 
This  result  did  not  occur  as  far  as  I was  enabled  to  judge  in  any  of 
the  cases  that  came  under  my  observation,  although  chloroform  was 
invariably  employed  when  operative  interference  was  required,  and 
particular  attention  was  paid  to  this  point  with  a view  of  ascertaining 
the  actual  influence  exercised  by  the  agent  in  this  respect. 

The  inhalation  of  chloroform  should  be  avoided  in  operations  about 
the  jaws  and  fauces  where  it  may  happen  that  in  consequence  of  the 
insensibility  of  the  patient  the  blood  will  flow  into  the  glottis  and 
produce  suffocation.  Ether,  producing  a much  less  sedative  effect 
upon  the  heart’s  action,  will  be  preferable  in  those  cases  in  which 
operations  are  to  be  performed  upon  patients  in  a sitting  posture,  or 
where  it  is  desirable  to  induce  only  a partial  anaesthesia,  that  the 
patient  may  cooperate  with  the  surgeon  during  the  performance  of 
operations  about  the  throat. 

When  chloroform  is  being  employed  the  patient  should  always  be 
placed  in  a recumbent  position.  About  a drachm  of  the  agent  is  poured 
upon  a towel  folded  in  the  shape  of  a cone  and  held  over  his  nose  and 
mouth,  some  little  distance  from  the  face,  that  the  air  may  be  freely 
mixed  with  the  vapor  as  it  passes  into  the  respiratory  passages. 


670 


ANAESTHESIA. 


I often  administered  it  bj  directing  a small  piece  of  cotton  cloth 
to  be  laid  over  the  patient’s  nose  and  mouth,  and  the  chloroform 
dropped  upon  this  in  small  quantities  at  a time,  until  the  desired  effect 
was  produced  ; the  cloth  being  thin,  permits  the  air  to  reach  the  lungs 
through  its  meshes  in  due  quantity.  In  order  to  prevent  the  loss  of 
the  chloroform  by  evaporation,  in  adopting  this  plan,  I usually  cover 
the  cloth  with  a piece  of  oiled  silk  of  corresponding  size ; the  lower 
margins  of  the  two  pieces  must  be  raised  a little,  so  that  the  air  may 
gain  ready  access  with  the  chloroform  during  the  inhalation.  Rapid 
anaesthesia,  economy  of  the  chloroform,  and  an  abundant  supply  of 
air  are  the  advantages  of  the  plan;  it  may  also  be  mentioned  that  the 
eyes  and  face  are  freed  from  the  contact  of  the  liquid. 

When  the  patient  has  been  fully  chloroformized,  the  inhalation 
should  be  momentarily  suspended,  and  afterwards  resumed  at  the 
moment  the  patient  shows  signs  of  returning  consciousness,  which 
will  be  evinced  by  some  muscular  effort.  The  quantity  of  chloroform 
poured  upon  the  towel  needs  to  be  diminished  at  every  dose.  In 
this  manner  anassthesia  may  be  safely  maintained  for  several  hours 
together;  during  this  time  the  patient  should  be  narrowly  watched, 
an  assistant  being  detailed  to  note  the  pulse  and  at  the  same  time 
attend  the  appearance  of  the  countenance  and  the  condition  of  the 
respiration.  The  moment  the  pulse  becomes  weak,  the  face  pale,  and 
the  respiration  embarrassed  or  stertorous,  danger  is  imminent,  and  the 
anaesthetic  must  be  discontinued. 

Sometimes  unpleasant  results  follow  want  of  attention  to  a certain 
preliminary  preparation,  which  is  of  the  first  importance  both  as  regards 
the  safety  of  the  patient  and  the  result  of  operations.  First,  before 
the  anaesthetic  is  administered  the  stomach  should  be  empty,  otherwise 
vomiting  will  almost  surely  follow  the  inhalation,  which,  in  operations 
upon  the  eye,  may  cause  the  loss  of  that  organ ; besides,  the  act  of 
emesis  being  attended  with  more  or  less  depression,  may  contribute 
measurably  to  the  suspension  of  the  heart’s  action,  already  enfeebled 
by  the  influence  of  the  chloroform.  Another  advantage  derived  from 
attending  to  this  point  is  that  the  diaphragm  will  have  freer  play  in 
sustaining  the  respiration  when  not  obstructed  by  a distended  stomach. 

Secondly,  all  articles  of  clothing  about  the  patient’s  person  should 
be  loosened,  so  that  the  walls  of  the  thorax  and  abdomen  be  not  com- 
pressed, to  the  detriment  of  a vigorous  respiration. 

Thirdly,  the  inhalation  should  be  gradual,  so  that  the  system  may 
have  time  to  accommodate  itself  to  the  altered  conditions  of  functional 
activity ; the  rapid  administration  of  chloroform  will  produce  a sort 
of  shock,  that  may  be  fatal. 

Fourthly,  the  surgeon  should  assure  himself  that  the  chloroform  is 
pure. 

The  article  obtained  from  methylated  spirit  is  the  best,  but  the  ordi- 
nary article  can  generally  be  depended  upon.  The  usual  impurities 
are  alcohol,  the  pyrogenous  oils,  and  ether.  If  we  place  in  a test-tube 
a little  distilled  water,  and  pour  into  it,  guttatim,  chloroform,  if  there 
is  any  alcohol  present  the  mixture  will  become  somewhat  milky,  but 
if  that  fluid  is  absent,  the  chloroform  will  fall  to  the  bottom  unchanged: 


ANAESTHESIA. 


671 


a little  of  the  albuminous  fluid  of  an  egg  added  to  chloroform  con- 
taining alcohol  will  be  promptly  coagulated.  When  poured  upon  the 
hand,  any  pyrogenous  oil  will  leave  upon  it  a greasy  feel  when  the 
chloroform  has  evaporated.  The  addition  of  sulphuric  acid  will 
change  the  color  of  the  oil  to  yellow  or  brown.  If  the  suspected 
fluid  be  poured  upon  a sheet  of  white  letter-paper,  it  leaves  a greasy 
spot,  produced  by  the  absorption  of  the  oil.  Adulteration  with  ether 
is  easily  recognized  by  applying  a flame  to  the  mixture,  which  imme- 
diately inflames ; pure-chloroform  is  combustible,  but  not  inflammable. 

The  quantity  of  chloroform  required  in  each  case  will  vary  with 
the  age,  sex,  and  susceptibility  of  the  patient,  and  the  duration  of  the 
operation ; generally  between  half  an  ounce  and  an  ounce  will  do, 
but  in  prolonged  operations  ten  to  sixteen  ounces  may  be  required. 
Young  children  require  very  little,  and,  as  a general  rule,  females  are 
more  susceptible  to  its  influence  than  males.  Age  is  no  bar  to  the 
administration  of  chloroform. 

If  the  agent  has  produced  poisonous  effects  indicated  by  the  changes 
in  the  countenance,  breathing,  and  pulse  mentioned  above,  the  inhala- 
tion must  be  instantly  suspended,  and  recourse  had  to  the  following 
means  of  resuscitation : — 

1.  Secure  the  largest  possible  supply  of  fresh  air  by  throwing  open 
the  windows  and  doors. 

2.  Dash  cold  water  upon  the  face  and  chest  of  the  patient. 

3.  Establish  artificial  respiration  by  Marshall  Hall’s  plan  for  inflat- 
ing the  lungs,  or,  what  I think  better,  that  known  under  the  name  of 
Dr.  Sylvester’s  method,  which  consists  in  raising  the  arm  above  and 
parallel  with  the  head  at  regular  intervals,  so  that  the  ribs  may  be 
alternately  elevated  and  depressed  fifteen  or  twenty  times  per  minute. 
A third  plan  is  also  recommended  by  some — inflating  the  lungs  by 
blowing  into  the  patient’s  mouth ; as  this  introduces  more  or  less  car- 
bonic acid  gas,  it  has  been  suggested  to  substitute  for  the  mouth  a pair 
of  bellows. 

4.  Run  the  point  of  the  index  finger  over  the  tongue  to  its  base, 
which  may  then  be  pressed  forward,  and  the  superior  opening  of  the 
larynx  gently  touched  so  as  to  excite  reflex  action. 

5.  Prof.  Nelaton  says  that  a plan  which  has  always  succeeded  with 
him,  and  never  to  be  neglected  in  these  cases,  consists  in  suspending 
the  patient  by  the  heels. 

6.  Counter-irritation  of  the  skin  by  percussing  it  with  the  hands, 
the  application  of  mustard  plasters,  mustard  baths,  &c. 

Stimulating  vapors,  such  as  that  of  liquor  ammonias,  may  be  held 
beneath  the  nose ; eDemas  of  oil  of  turpentine  will  also  be  of  service. 
As  soon  as  the  patient  can  swallow,  brandy  or  other  stimulant  should 
be  given. 

It  has  been  recommended  to  pass  an  electrical  current  along  the 
spine. 

The  same  amount  of  care  is  not  required  in  administering  ether  as 
chloroform,  as  it  does  not  act  near  so  energetically  as  the  latter. 

The  inhalation  may  be  effected  by  pouring  the  ether  into  a coni- 


672 


ANAESTHESIA. 


cally-shaped  sponge  moistened  with  water  and  covered  with  oiled  silk : 
a folded  napkin  or  towel  will  also  answer  very  well. 

The  first  dose  for  an  adult  may  be  half  an  ounce ; the  first  whiffs  of 
the  vapor  generally  produce  a slight  cough  and  acts  of  deglutition, 
which  soon,  however,  subside  and  are  followed  by  a condition  of  ex- 
hilaration, sometimes  violent  excitement ; in  a few  seconds  the  patient 
becomes  quiet,  muscular  relaxation  and  complete  insensibility  ensu- 
ing- 

When  the  patient  begins  to  recover  from  the  anaesthesia,  he  gene- 
rally evacuates  the  contents  of  the  stomach,  if  it  happens  to  contain 
anything.  He  feels  confused,  and  there  is  some  pain  in  the  head,  which 
last  sometimes  continues  a day  or  two ; the  odor  of  the  vapor  also 
hangs  to  the  patient’s  breath  for  two  or  three  days. 

The  quantity  of  ether  required  in  each  case,  under  ordinary  cir- 
cumstances, will  be  from  four  to  six  fluidounces,  but  in  prolonged 
operations  as  much  as  fifteen  or  twenty  ounces  may  be  demanded.  To 
produce  complete  anaesthesia  the  vapor  must  be  breathed  at  least  ten 
or  twelve  minutes,  and  sometimes  it  takes  twenty  or  thirty,  according 
to  the  age  and  susceptibility  of  the  patient. 

The  whole  series  of  ethers  possess  properties  analogous  to  those  of 
sulphuric  ether. 

Other  agents  besides  the  ethers  and  chloroform  have  been  used  as 
anaesthetics,  among  which  are  chlorocarbon,  chloride  of  olefiant  gas, 
bromide  of  ethyl,  amylene,  and  keroselene.  Chlorocarbon,  or  the 
bichloride  of  carbon,  is  a transparent,  colorless  fluid,  having  an  ethereal 
odor  and  sweetish  taste,  not  unlike  chloroform,  to  which  it  still  further 
assimilates  in  its  quality  and  effects,  but  is  more  dangerous  than  it, 
from  the  greater  depressing  influence  exercised  over  the  actions  of  the 
heart.  The  chlorocarbon  has  been  used  by  inhalation,  introduced  into 
the  stomach,  and  in  the  form  of  a vapor  douche.  In  the  latter  mode 
particularly  has  it  been  found  advantageous  in  hysteralgia,  and  pain- 
ful affections  of  the  rectum.  Prof.  Simpson  employed  a simple  appara- 
tus for  the  application  of  the  douche,  consisting  of  a common  enema 
syringe  with  the  nozzle  introduced  into  the  vagina,  and  the  other  ex- 
tremity of  the  apparatus  placed  an  inch  or  more  down  into  the  interior 
of  a four  ounce  phial  containing  a small  quantity,  as  an  ounce  or  so, 
of  the  fluid  whose  vapor  it  is  wished  to  inject  through  the  syringe. 

Chloride  of  olefiant  gas  and  the  bromide  of  ethyl  have  both  been 
used  by  Mr.  Nunnely,  of  Leeds,  and  he  believes  them  to  possess  im- 
portant advantages  over  chloroform.  Patients  can  be  put  under  their 
influence  and  kept  insensible  for  any  length  of  time,  during  the  per- 
formance of  the  most  painful  operations;  both  these  agents  act  speedily, 
pleasantly,  and  well. 

Amylene  was  experimented  with  by  MM.  Caillot  and  Giraldbs,  and 
made  the  subject  of  a report  to  the  Academy  of  Medicine  by  M.  Robert. 
This  agent  is  extremely  fetid,  produces  the  most  violent  symptoms  in 
a few  moments,  while  they  as  rapidly  pass  away.  It  has  proved  fatal 
in  one  case  in  the  hands  of  Dr.  Snow,  of  London,  and,  possessed  of 
much  safer  and  more  convenient  anaesthetics,  the  profession  has  very 
properly  abandoned  its  use. 


ANAESTHESIA. 


673 


Keroselene,  a liquid  hydrocarbon  with  a tasteless  and  unirritating 
vapor,  has  been  but  lately  brought  forward,  and  requires  further  ex- 
periments to  ascertain  its  value  as  an  anaesthetic. 

Several  other  agents  possess  anaesthetic  properties  in  some  degree, 
but  they  are  of  no  practical  value,  inasmuch  as  the  majority  of  them 
have  not  been  tried  upon  the  human  subject.  The  reader  is  referred 
for  further  information  as  regards  these  agents  to  The  Transactions  of 
the  Provincial  Med.  and  Surg.  Association,  London,  vol.  xvi.  p.  177. 


48 


INDEX 


Abdominal  bandages,  142,  183 
herniae,  255 
Actual  cautery,  577 
Acupuncture,  591 
Acupressure,  652 
Adhesive  plaster,  56 

mode  of  preparing,  56 
use  of,  56 

application  of,  in  the  treatment  of  ulcers, 
147 

in  the  treatment  of  club-foot,  323 
in  the  treatment  of  orchitis,  150 
Agnew’s  apparatus  for  coxalgia,  342 
Aigrette  of  the  silk-cotton  tree  as  a dressing,  49 
of  the  silk-weed  as  a dressing,  50 
Amadou  as  a dressing,  50 
Ammonia  as  an  antiseptic,  121 
Anaesthesia,  665 
Anchylosis,  319 
Anel’s  syringe,  107 
probe,  619 

Aneurism,  mechanical  treatment  of,  145 
Ankle,  dislocation  of,  561 
Ankle-joint,  compound  dislocation  of,  567 
Angular  curvature  of  the  spine,  310 
cervical  curvature,  293 
Antiseptics,  121 
ammonia,  121 
bisulphate  of  soda,  121 
bromine,  121 
carbolic  acid,  121 
Anus,  prolapsus  of,  268 

Apparatus  for  angular  cervical  curvature,  293 
for  angular  curvature  of  the  spine,  312 
for  anterior  curvature  of  the  leg,  333 
for  applying  carbonic  acid  to  the  uterus, 
130 

for  bowed  legs,  332 
for  bunion,  321 
for  club-foot,  323 
for  contraction  of  the  knee,  333 
for  coxalgia,  343 
of  Dr.  Davis  for  coxalgia,  339 
for  deficiency  of  the  abdominal  walls,  227 
of  the  chin,  226 
of  the  cranial  walls,  219 
of  the  eye,  223 
of  the  integuments,  220 
of  the  lips  and  cheeks,  223 
of  the  lower  extremities,  237 
of  the  nose,  221 
of  the  palate,  223 
of  the  trunk,  227 
of  the  upper  extremities,  228 
of  the  walls  of  the  spinal  canal,  228 


Apparatus — 

for  deformity  of  the  chin  and  neck,  292 
of  the  elbow,  319 
of  the  finger,  317 
of  the  lips,  291 
of  the  wrist,  318 
of  dressing,  33 

for  extending  a contracted  stump,  242 
for  immobility  of  the  lower  jaw,  290 
for  lateral  curvature  of  the  spine,  304 
for  loss  of  function  of  the  cervical  muscles, 
253 

of  the  dorsal  muscles,  254 
of  the  ligaments  of  the  hip-joint,  289 
of  the  ligaments  of  the  knee-joint,  287 
of  the  muscles  of  the  head  and  neck, 
252 

of  the  muscles  of  the  thumb,  275 
of  the  muscles  of  the  trunk,  233 
of  parts  of  the  body,  250 
of  parts  of  the  lower  extremities,  280 
of  parts  of  the  upper  extremities,  274 
for  loss  of  symmetry  of  the  lower  extremi- 
ties, 320 
of  parts,  289 
of  the  pelvis,  314 
of  the  trunk,  297 
of  the  upper  extremities,  315 
for  paralysis  of  the  biceps,  279 

of  the  common  extensor  of  the  fin- 
gers, 277 

of  the  extensors  of  the  hand,  278 
of  the  interossei  muscles  of  the  fin- 
gers, 276 

of  the  lower  extremities,  284 
of  the  peronei  muscles,  282 
of  the  scapula  muscles,  280 
of  the  tibialis  anticus,  281 
for  prolapsus  ani,  268 
for  posterior  curvature  of  the  spine,  310 
of  the  neck,  292 
for  single  lateral  curvature,  309 
for  talipes  calcaneus,  331 
for  torticollis,  295 

Application  of  atomized  liquids  to  the  interior 
cavities,  126 

of  hot  air  to  wounds,  124 
Application  of  trusses,  261 

of  vapors  and  gases  to  the  skin,  123 
of  water  by  means  of  India-rubber  sacks, 
95 

of  water  to  the  head,  96 
to  the  neck,  97 
to  the  spine,  97 
to  the  chest,  97 


676 


INDEX. 


Application  of  water — 

to  the  abdomen,  97 
to  the  limbs,  98 

Arm,  application  of  tourniquet,  548 
Artery -forceps,  38 

Arteries,  method  of  applying  a ligature  to 
bleeding,  651 
tortion  of,  654 
Arteriotomy,  606 

Artificial  arm  of  Ambrose  Pare,  228 
of  Beehard,  231 
of  Charriere,  230 
common,  234 

of  Gotz  yon  Berlichingen,  229 
of  Kolbe,  234 
of  Gildea,  233 
of  Van  Petersen,  229 
with  driying  hook  attached,  235 
eye,  222 
foot,  239 
leg  of  Bly,  245 

of  Beehard,  250 
of  Charriere,  250 
of  Ferd.  Martin,  250 
of  Palmer,  249 
of  Kolbe,  247 
of  Mille,  250 
of  Mathieu,  250 
of  Beaufoy,  242 

for  amputation  below  the  knee,  241 
nose,  221 
palate,  224 

of  Dr.  Ilullihen,  225 
Astragalus,  dislocation  of,  567 
Atomizer  of  Sales-Girons,  128 
steam,  129 

Bandages — 

anterior  figure  of  8 of  the  head  and  axilla, 
178 

anterior  figure  of  8 of  the  shoulders,  180 
anterior  double  T of  the  head  and  chest, 
184 

anterior  figure  of  8 of  the  hand  and  wrist, 
198 

anterior  figure  of  8 of  the  knee,  210 
anterior  sling  bandage  of  the  hand,  202 
bandage  for  the  leg,  217 
for  the  foot,  217 
binocle,  162 

bis-oculo-occipital  triangle,  172 
cap  of  the  breast,  1S6 
x of  {he  head,  173 

carpo-oleeranon  cravat,  204 
carpo-eervical  triangle,  205 
carpo-digito-dorsal  triangle,  203 
cervico-thoraeic  cravat,  1S9 
cervico-dorso -sternal  cravat,  1S9 
cervico-axillary  cravat,  191 
cervico-braehial  triangle,  205 
circular  bandage  of  the  leg,  207 
of  a toe,  207 
of  a finger,  194 
of  the  forearm,  194 
of  the  neck,  176 
of  the  chest  and  abdomen,  176 
of  the  forehead  and  eyes,  160 
circular  cravat,  172 

compound  metatarso-patellar  cravat,  215 
bis-axillary  cravat,  188 
dorso-bis-axillary  cravat,  189 
coxo-pelvic  triangle,  191 


Bandages — 

crossed  bandage  of  the  chest,  180 
of  one  breast,  181 
of  both  breasts,  182 
of  one  groin,  182 
of  both  groins,  183 
of  the  head  and  neck,  165 
of  the  head,  165 
cravat  for  the  neck,  187 
crucial  bandage  of  the  head,  169 
cruro-pelvic  cravat,  190 
cravats  for  the  lower  extremities,  215 
for  the  upper  extremities,  203 
deltoid  bandage,  205 
double  T bandage  of  the  foot,  213 
double  T bandage  of  the  hand,  201 
, double  T of  the  pelvis,  184 

double  T of  the  chest  and  abdomen,  183 
double  T of  the  head,  168 
double  T of  the  nose,  168 
double  crossed  bandage  of  the  lower  iaw, 
163 

dorsal  triangle,  192 

extensor  figure  of  8 bandage  of  the  hand 
and  forearm,  199 
facial  triangle,  173 

figure  of  8 of  the  head  and  one  axilla, 
177 

figure  of  8 of  the  neck  and  axilla,  178 
figure  of  8 of  the  thumb  and  wrist,  198 
figure  of  8 of  the  elbow,  198 
figure  of  8 of  a toe,  209 
figure  of  8 of  the  foot  and  leg,  210 
figure  of  8 of  both  knees,  2 1 0 
four-tailed  bandage  of  the  chin,  170 
fronto-cervico-labial  triangle,  173 
fronto-oeulo-oecipital  triangle,  172 
fronto-occipital  triangle,  172 
fronto-thoracic  triangle,  188 
flexor  figure  of  8 of  the  hand  and  fore- 
arm, 199 
girdle,  193 

half  cap  of  the  head,  173 
imbricated  squares  and  cravats  for  the 
lower  extremity,  215 
invaginated  bandage  for  transverse 
wounds,  212 

for  longitudinal  wounds,  211 
for  the  lips,  167 
interdigital  triangle,  204 
intercrural  cravat,  190 
knotted  bandage  of  the  head,  165 
laced  bandage  of  the  lower  extremity, 
214 

of  the  body,  206 
of  the  arm,  203 

large  quadrilateral  scarf  of  the  arm  and 
chest,  200 

lateral  thoracic  bandage,  191 
mask,  171 

malleolar-phalangeal  triangle,  216 
metatarso-malleolar  cravat,  216 
monocle,  162 

oblique  bandage  of  the  neck  and  axilla, 
177 

oblique  quadrilateral  scarf  of  the  arm  and 
chest,  200 

oecipito-frontal  triangle,  172 
occipito-mental  triangle,  172 
occipito-auricular  triangle,  173 
ocular  triangle,  174 
palmo-digito-brachial  triangle,  204 


INDEX. 


677 


Bandages — 

parieto-axillary  triangle,  1S9 
perforated  T bandage  of  the  hand,  202 
posterior  figure  of  8 bandage  of  the  knee, 
210 

posterior  sling  bandage  of  the  elbow,  202 
posterior  figure  of  8 of  the  hand  and 
wrist,  198 

quadrilateral  bandage  of  the  head,  107 
recurrent  bandage  of  the  hip,  211 
of  the  thigh,  211 
of  the  leg,  211 
of  a stump  of  an  arm,  199 
after  disarticulation  at  the  shoulder, 
199 

of  the  head,  166 
sacro-lumbar  triangle,  190 
saero-bicrural  cravats,  190 
sacro-pubic  triangle,  189 
scarf  of  the  arm  and  neck,  201 
of  the  hand  and  forearm,  201 
sheath  bandage  of  the  nose,  171 
of  the  tongue,  171 
of  the  fingers,  194 
of  a toe,  204 
sheath  of  the  penis,  187 
shepherd's  sling,  174 
simple  bis-axillary  cravat,  188 
simple  dorso-bis-axillary  cravat,  189 
single  T bandage  of  the  hand,  201 
single  T bandage  of  the  foot,  213 
simple  crossed  bandage  for  the  lower  jaw, 
163 

six-tailed  bandage  of  the  head,  170 
sling  bandage  of  the  hand,  202 
of  the  shoulder,  185 
of  the  breast,  185 
of  the  hip,  186 
of  the  instep,  213 
of  the  heel,  214 
of  the  knee,  214 
strait-jacket,  202 
spica  of  the  shoulder,  179 
suspensory  of  the  testicle,  187 
spiral  bandage  of  the  body,  177 
sternal  triangle,  191 
spiral  bandage  of  a toe,  201 
of  the  leg,  208 
of  the  thigh,  208 
of  the  lower  extremities,  208 
of  a finger,  195 
of  all  the  fingers,  195 
of  the  hand  and  fingers,  196 
of  the  forearm,  196 
of  the  arm,  196 
of  the  whole  arm,  197 
tarso-pelvic  cravat,  216 
tarso-crural  cravat,  216 
tarso-patellar  cravat,  215 
T bandage  of  the  mouth,  169 
T bandage  of  the  groin,  184 
T bandage  of  the  head,  168 
T bandage  of  the  head  and  ears,  168 
thoracico-scapular  triangle,  189 
tibial  triangle,  215 
triangular  cap  of  stumps,  205 
of  the  shoulder,  205 
for  stumps,  216 
for  the  heel,  216 
of  the  breast,  189 

triangular  bandage  of  the  head,  167 
triangle  of  the  trochanter  major,  217 


Bandages — 

uniting  cord  for  longitudinal  wounds,  217 
Bandage-scissors,  148 

BarwelPs  mode  of  attaching  elastic  cords  in 
club-foot,  323 
splint  for  coxalgia,  341 
Baths,  98 

general,  98 
shower,  101 
vapor,  102 
warm  air,  104 
dry,  104 
local,  104 
hip,  103 
foot,  106 
Bathing,  98 

Baynton’s  plan  of  healing  ulcers,  187 
Bedsores,  97 
Belloc’s  sound,  621 

Bigg’s  apparatus  for  caries  of  the  cervical 
vertebrae,  294 
for  torticollis,  296 
for  lateral  curvature,  306 
for  contracted  knee,  336 
for  immobility  of  the  lower  jaw,  290 
Bigg’s  couch  for  lateral  curvature  of  the  spine, 
202 

Bishop’s  apparatus  for  caries  of  the  cervical 
vertebras,  294 
Bistouries,  35 
straight,  35 

curved  sharp-pointed,  36 
curved  probe-pointed,  36 
Bisulphate  of  soda  as  a disinfectant,  120 
Blisters,  575 
Bloodletting,  600 

Bonnet’s  apparatus  for  anchylosis  of  the  elbow, 
319 

for  torticollis,  295 
for  contraction  of  the  knee,  334 
Bougies,  625 

introduction  of,  into  the  oesophagus,  623 
into  the  bladder,  625 
Bourdonnet,  47 

mode  of  making,  47 
use  of,  47 

Bowed  or  bandied  legs,  331 
Bran-dressing,  Barton's,  50 
Brodie’s  apparatus  for  lateral  curvature,  307 
Bromine  as  an  antiseptic,  121 
Buchanan’s  compound  circular  catheter,  152 
Bullet  of  lint,  46 

mode  of  making,  46 
uses  of,  46 
Bullet-forceps,  664 
Bunion,  321 

Bunsen’s  battery  for  cauterization,  581 
Burns,  149 

treatment  of,  with  adhesive  strips,  149 

Canula  for  polypi,  156 
Carbon  as  a disinfectant,  120 
Carbonic  acid  gas  in  vesical  disease,  130 
Carbolic  acid  as  a disinfectant,  121 
Carpus,  dislocations  of,  539 
fractures  of,  434 
Carte’s  compressors,  146 
Cartilages,  semilunar,  dislocation  of,  560 
Cataplasms,  79 

retentive  bandage  for,  81 
Catch-forceps,  39 
Catheters,  silver,  44 


678 


INDEX 


Catheter,  double,  for  injecting  the  bladder,  94 
male,  44 
female,  629 
syringe,  109 

Cat’s  tail  as  a dressing,  50 
Catheterism,  618 

of  the  nasal  duct,  619 
of  the  Eustachian  tube,  620 
of  the  posterior  nares,  621 
of  the  oesophagus,  623 
of  the  larynx  and  trachea,  624 
of  the  large  intestines,  625 
of  the  uterus,  625 
of  the  urethra,  625 
of  the  male  urethra,  625 
of  the  female  urethra,  629 
Cauterization,  577 
actual,  577 
galvanic,  579 
potential,  581 
Cauteries,  578 
Caustic-holder,  42 
Cerates,  62 

extemporaneous  formulae  for,  63 
Charriere’s  compressor,  146 
Charpie,  45 

mode  of  making,  45 
different  sorts  of,  45 
Chassaignac’s  ecraseur,  157 
Chloropercha,  59 
Chlorine  as  a disinfectant,  118 
Chloroform,  use  of,  in  operations,  668 
Chloride  of  zinc  as  a disinfectant,  120 
Cinnabar  and  the  oxide  of  arsenic  as  disin- 
fectants, 121 
Clamp,  Hoey’s,  146 
Classification  of  bandages,  158 
Clavicle,  dislocations  of,  517 
fracture  of,  397 
Closure  of  jaws,  290 
Clove-hitch,  507 
Club-foot,  322 
Coins  in  oesophagus,  635 
in  trachea,  637 
Cold  water-dressings,  87 
Cold,  application  of,  in  inflammation,  87 
Collodion,  58 

mode  of  preparing,  58 
how  used,  58 
Collutories,  78 

extemporaneous  forms  of,  79 
Collyria,  74 

Common  socket  leg,  241 
Compound  bandages,  158 
Compression  bandages  in  fractures,  144 
for  stumps,  144 
in  aneurism,  145 
Compressor,  145 
Carte’s,  146 
Charriere’s,  146 
Wales’s,  147 

Compressive  bandages,  144 
Compresses,  52 
folded,  52 
square,  52 
triangular,  52 
oblong,  52 
perforated,  52 
fenestrated,  52 
button-hole,  52 
single-split,  52 
double-split,  52 


Compresses — 

many  split,  52 
sling,  52 
graduated,  54 

Constitutional  disturbance  in  fracture,  350 
Contused  wounds,  662 
Contraction  of  fingers,  315 
of  thumb,  315 
of  the  knee-joint,  333 
of  the  hip,  336 
of  the  wrist,  317 
of  the  toes,  320 

Corrigan’s  button  cautery,  572 
Coracoid  process,  fracture  of,  394 
Corne  and  Demeau’s  disinfectant,  120 
Cotton,  48 
use  of,  48 

Counter-irritation,  571 
Counter-irritants,  different  kinds  of,  570 
actual  cautery,  578 
blisters,  575 
caustic  potash,  582 
dry  cupping,  609 
issue,  586 
moxa,  585 
nitrate  of  silver,  582 
seton,  589 
sinapisms,  572 
tartar  emetic,  64 
Coxalgia,  337 
Cranium,  fractures  of,  573 
Crepitus,  348 
Cupping,  608 
dry,  608 

Curvatures  of  spine,  297 
angular,  310 
posterior,  309 
lateral,  297 

Davis’s  mode  of  treating  coxalgia, 339 
Deficiency  of  the  arm,  2S8 
of  the  cranial  walls,  219 
of  the  chin,  226 
of  the  ear,  223 
of  the  eye,  222 
of  the  integuments,  219 
of  the  leg,  237 
of  the  lips  and  cheeks,  223 
of  the  nose,  220 
of  the  palate,  223 
of  the  teeth,  226 
of  the  thoracic,  227 
of  the  walls  of  the  spinal  canal,  228 
Deformities  of  the  chin  and  neck,  291 
of  the  elbow,  318 
in  fracture,  349 
of  the  finger,  315 
of  the  foot  and  ankle,  322 
of  the  lips  from  burns,  291 
of  the  nose,  289 
of  the  wrist,  317 
Deligation  of  arteries,  650 
Deprivation  of  function  in  fracture,  349 
Dewar’s  apparatus  for  supporting  suture  in 
hare-lip,  143 
Diastasis,  346 
Dilatation,  151 

of  lachrymal  canals,  151 
of  stricture  of  oesophagus,  151 
neck  of  uterus,  151 
vagina,  151 
urethra,  151 


INDEX. 


679 


Dilators,  151 

oesophageal,  151 
uterine,  151 
vaginal,  151 
urethral,  151 
Buchanan’s,  152 
Sheppard’s,  153 
wire,  152 
Wakely’s,  153 
Director,  42 
use  of,  42 
Disinfection,  117 
Disinfectants,  117 

Ledoyen’s  disinfecting  fluid,  118 
carbon,  120 
cleanliness,  121 
chloride  of  soda,  118 
chloride  of  zinc,  120 
chlorine,  118 
bisulphite  of  soda,  120 
gunpowder,  120 
Sir  W.  Burnett’s,  120 
ozone,  119 
Labarraque’s,  118 
permanganate  of  potassa,  120 
sulphurous  acid  gas,  120 
sulphite  of  soda,  120 
mixture  of  MM.  Corne  and  Demeau,  120 
mixed  gases  of  chlorine  and  hydrochloric 
acid,  119 
Dislocation,  500 
causes  of,  502 

continuous  elastic  extension  in,  510 
diagnosis  of,  506 
frequency  of,  501 
nomenclature  of,  500 
of  the  astragalus  upon  the  tibia,  561 
forwards,  561 
backwards,  562 
inwards,  563 
outwards,  564 
upwards,  565 
by  rotation,  565 
of  the  carpus,  539 
backwards,  539 
forwards,  540 
of  the  clavicle,  517 

a.  inner  extremity,  518 

forwards,  518 
upwards,  519 
backwards,  520 

b.  outer  extremity,  520 

upwards,  520 
downwards,  522 

downwards  under  coracoid  pro- 
cess, 523 

c.  both  extremities,  523 
of  the  femur,  548 

iliac,  548 
sciatic,  551 
thyroid,  552 
pubic,  554 
unusual,  555 
of  the  fibula,  560 

a.  upper  extremity,  560 

forwards,  560 
backwards,  560 

b.  lower  extremity,  561 

backwards,  561 
of  the  foot,  561 
of  the  head  and  trunk,  511 
of  the  humerus,  523 


Dislocation  of  the  humerus — 
backwards,  531 
downwards,  523 
forwards,  530 

of  the  inferior  maxilla,  511 
bilateral,  511 
unilateral,  511 
of  the  lower  jaw,  511 
of  the  lower  extremities,  547 
of  the  metacarpus,  541 
of  the  metatarsus,  568 
of  the  os  magnum,  540 
of  the  patella,  556 
outwards,  556 
inwards,  557 
upwards,  557 
upon  its  own  axis,  557 
of  the  pelvic  bones,  547 
ilium,  547 
sacrum,  547 
coccyx,  547 

of  the  phalanges  of  the  fingers,  542 
of  the  phalanges  of  the  toes,  569 
of  the  pisiform  bone,  541 
of  the  radius  and  ulna,  532 
backwards,  532 
forwards,  534 
outwards,  535 
inwards,  535 

radius  forwards  and  ulna  backwards, 
536 

of  the  radius,  536 
backwards,  536 
forwards,  537 
outwards,  538 

of  the  ribs  and  costal  cartilages,  516 
of  the  semilunar  bone,  541 
of  the  semilunar  cartilages,  560 
of  the  sternum,  516 
of  the  tarsal  bones,  565 
astragalus,  565 
forwards,  566 
backwards,  566 
inwards,  566 
outwards,  566 
os  calcis  and  scaphoid,  567 
backwards,  567 
inwards,  567 
outwards,  567 
cuboid  and  scaphoid,  568 

forwards  and  upwards,  568 
scaphoid,  568 

forwards,  568 
cuneiform  bones,  568 
forwards,  568 
of  the  tibia,  557 
backwards,  558 
forwards,  558 
inwards,  559 
of  the  ulna,  538 

upper  extremity,  538 
backwards,  538 
lower  extremity,  539 
forwards,  539 
backwards,  539 
of  the  unciform  bone,  541 
of  the  upper  extremities,  517 
of  the  vertebrae,  514 
pathological  anatomy  of,  503 
prognosis  of,  506 
symptoms  of,  504 
treatment  of,  566 


680 


INDEX. 


Dividing  bandages,  143 
Double  canula  of  Levret,  156 
Double-headed  roller,  136 
mode  of  application,  136 
Douche,  104  • 

Dressings,  88 

warm  water,  87 
cold  water,  89 
medicated  water,  89 
of  wounds,  658 
Drop-wrist,  278 
Dry  fomentations,  89 

Duchenne’s  apparatus  for  lateral  curvature, 
307 

for  paralysis  of  the  common  extensors  of 
the  fingers,  277 

for  paralysis  of  the  interossei  muscles,  276 
Dupuytren’s  bandage,  53 
compressor,  649 

Ear,  removal  of  foreign  bodies  from,  632 
Earle’s  triple-inclined  plane  for  curvature  of 
spine,  312 
Ecraseur,  157 

mode  of  action  of,  157 
wire,  157 

Eighteen-tailed  bandage,  53 
Elastic  cords  in  the  treatment  of  club-foot, 
323 

Electro-puncture,  592 
Epiphyses,  separation  of,  420 
Epistaxis,  621 
Ether,  671 

Eustachian  catheter,  620 
Expelling  bandages,  143 
Extraction  of  teeth,  614 
Eye,  removal  of  foreign  bodies  from,  632 
vapors,  75 
powders,  75 
salves,  75 

Fibula,  dislocations  of,  560 
Finger,  fractures  of,  435 

use  of  as  a director,  598 
First  pieces  of  dressing,  44 
Flexed  knee,  333 
Folded  compresses,  54 
Fomentation,  89 
Foot-bath,  106 
Forceps,  38 

dressing.  38 
artery,  38 

with  slide,  38 
with  spring,  38 

for  holding  pins  in  making  the  twisted 
suture,  39 
Liston’s,  39 
tooth-pointed,  40 
for  extracting  teeth,  614 
Foreign  bodies,  removal  of  from  ear,  632 
from  the  nostrils,  635 
from  the  rectum,  641 
from  the  trachea,  637 
Formulae  for  collyria,  76 
for  eye-powders,  79 
for  eye-salves,  76 

for  injections  into  the  urethra,  109 
into  the  bladder,  110 
into  the  rectum,  114 
Fractures,  346 

adhesive  straps  in,  469 
apparatus  for,  357 


Fractures — 

causes  of,  347 

chalk  and  gum  bandages  in,  364 

classification  of,  346 

complicated,  355 

compound,  354 

definition  of,  346 

dextrine  bandages  in,  367 

diagnosis  of,  350 

dressings  of,  358 

frequency  of,  347 

general  treatment  of,  355 

gutta  percha  in,  363 

immovable  apparatus  in,  365 

mode  of  repair,  350 

of  the  astragalus,  493 

of  the  calcaneum,  493 

of  the  carpus,  434 

of  the  clavicle,  397 

of  the  coccyx,  436 

of  the  costal  cartilages,  343 

of  the  femur,  437 

of  the  upper  extremity  of  the  femur,  437 
intra-capsular,  of  the  neck  of  the  femur, 
437 

extra-capsular,  of  the  neck  of  the  femur, 
444 

of  the  trochanter  major,  447 
of  the  shaft,  448 
of  the  condyles,  470 
of  the  fibula,  491 
of  the  head,  373 
of  the  humerus,  409 

anatomical  neck  of,  409 
tubercles  of,  419 

vertical  fracture  of  the  head  of,  410 
surgical  neck  of,  410 
shaft  of,  413 
condyles  of,  415 
external  condyle  of,  421 
internal  condyle  of,  422 
internal  epicondyle  of,  422 
of  the  hyoid  bone,  386 
of  the  ilium,  436 

of  the  inferior  maxillary  bone,  378 

of  the  laryngeal  cartilages,  3S7 

of  the  leg,  480 

of  the  lower  jaw,  378 

of  the  lower  extremities,  435 

of  the  malar  bone,  378 

of  the  metacarpus,  434 

of  the  nasal  bones,  374 

of  the  patella,  471 

of  the  pelvis,  435 

of  the  sacrum,  435 

of  the  coccyx,  436 

of  the  ilium,  436 

of  the  pubis  and  ischium,  436 

of  the  phalanges  of  the  fingers.  435 

of  the  phalanges  of  the  toes,  494 

of  the  radius  and  ulna,  423 

of  the  radius,  425 

upper  extremity  of,  425 
shaft  of,  426 
lower  extremity  of,  426 
of  the  ribs,  511 
of  the  sacrum,  435 
of  the  scapula,  393 

acromion  process  of,  393 
coracoid  process  of,  394 
neck  of,  394 
body  of,  395 


INDEX. 


681 


Fractures — 

inferior  angle  of,  396 
of  the  skull,  373 
of  the  sternum,  390 
of  the  superior  maxillary  bone,  376 
of  the  tarsus,  493 
of  the  tibia  and  fibula,  480 
of  the  tibia,  490 
of  the  ulna,  431 

olecranon  process  of,  431 
coronoid  process  of,  433 
shaft  of,  433 

of  the  upper  extremities,  393 
of  the  upper  jaw,  376 
of  the  vertebrae,  388 
lumbar,  388 
dorsal,  389 
cervical,  389 
of  the  zygoma,  378 
plaster  of  Paris  splint  in,  368 
pasteboard  splints  in,  359 
prognosis  of,  350 
seat  of,  347 
splints  for,  357 
Scultetus’  apparatus  for,  372 
starched  apparatus  for,  366 
symptoms  of,  348 
ununited,  352 

treatment  of,  352 
varieties  of,  346 

Fricke’s  plan  of  treating  orchitis  with  adhe- 
sive strips,  150 
Fumigation,  123 
general,  123 
local,  123 

Galvanic  issue,  588 
Gargles,  77 

formulae  for,  78 
Gariel’s  compressor,  150 
Gases  and  vapors,  uses  of,  117 
Gateau,  46 

mode  of  preparing,  46 
General  baths,  98 

rules  for  the  preparation  and  application 
of  bandages,  131 
bleeding,  600 
Genu-valgum,  284 
Glycerine,  70 

as  a dressing,  71 
extemporaneous  formulae  for,  72 
Gross’s  arterial  compressor,  649 
Gunshot  wounds,  663 
Gunpowder  as  a disinfectant,  120 
Gutta-percha  shoe  in  club  foot,  325 
shield  for  cervical  curvature,  294 

Half  Maltese  cross,  53 

mode  of  preparing,  53 
Hammer  toe,  320 

Hartshorne,  E.,  method  of  treating  fracture  of 
the  patella,  477 
of  the  olecranon,  478 
of  the  clavicle,  408 
Hemorrhage,  mode  of  arresting,  642 
Hernial  bandages,  254 
Hernia,  255 

inguinal,  255 
crural,  255 
ischiatic,  255 
obturator,  255 
perineal,  255 


Hernia — 

pudendal,  255 
umbilical,  255 
vaginal,  255 
ventral,  255 
Hip-bath,  106 
Hip  disease,  337 
Hoey’s  clamp  for  aneurism,  146 
Hypodermic  injection,  146 
syringe,  115 

Ilium,  fractures  of,  436 
Immersion,  89 

mode  of  employing,  90 
Immobility  of  lower  jaw,  290 
Improper  bandaging  in  amputation,  145 
Importance  of  the  early  treatment  in  deformi- 
ties, 218 

Incised  wounds,  655 
Incisions,  596 
India-rubber  cap,  95 
sac  for  neck,  96 
spine,  97 
abdomen,  97 
limbs,  98 

pads  for  splints,  358 

in  the  treatment  of  umbilical  hernia,  260 
suture,  660 

Indications  answered  by  bandages,  139 
Influence  of  climate  on  the  healing  of  wounds, 
124 

Inguinal  truss,  256 
Inhalation,  126 

of  camphor,  126 
of  the  narcotics,  126 
of  nitrate  of  potassa,  126 
of  iodoform,  127 
of  oxygen,  127 
of  chlorine,  127 
of  atomized  fluids,  128 
Inhalers,  126 
Injections.  106 

of  the  lachrymal  duct,  107 
of  the  ear,  107 
of  the  urethra,  109 
of  the  bladder,  100 
of  the  vagina,  110 
of  the  uterus,  1 1 1 
of  the  rectum,  112 
of  the  cellular  tissue,  115 
of  the  abnormal  canals,  116 
Instruments  for  dressing,  33 
Interrupted  suture,  659 
Introduction  of  catheter,  626 
of  pessaries,  273 
Irons  for  the  actual  cautery,  578 
Irrigations,  90 

mode  of  applying,  92 
cold,  92 
warm,  92 
of  nasal  fossas,  93 
of  the  bladder,  94 
of  vagina  and  uterus,  94 
Isinglass  plaster,  58 

mode  of  preparing,  58 
use  of,  58 
Issue,  586 

Jarvis’s  apparatus  for  reducing  dislocations, 
510 

Joints,  false,  352 

Jorg’s  apparatus  for  torticollis,  295 


682 


INDEX. 


Keroselene,  673 
Knock  knee,  284 
Knot-tighteners,  156 
Graefe’s,  156 
Iloderic’s,  156 
Knots,  55 

clove  hitch,  55 
double  noose,  56 
double,  55 
double  bow,  55 

double  knotted  and  looped,  56 

crossed  slip,  56 

loop,  55 

packer’s,  55 

reef,  55 

single  noose,  55 
bow,  55 
single,  55 
surgeon's,  56 
sailor’s,  56 
single  slip,  56 
weaver’s,  56 

Kolbe’s  apparatus  for  club-foot,  326 

for  contraction  of  the  knee,  333 
for  lateral  curvature,  308 
for  torticollis,  296 

Labarraque’s  disinfectant  solution,  118 
Lancet,  40 

Syme’s,  40 
spring,  603 
abscess,  41 
thumb,  40 
gum,  41 

Lateral  curvature  of  the  spine,  297 
Ledo.ven’s  disinfecting  fluid,  118 
Leeches,  611 
Leeching,  610 

Leeches,  hemorrhage  from  wounds  made  by, 
612 

Leg,  application  of  tourniquet  to,  615 
Ligatures,  154 

mode  of  action  of,  154 
mode  of  applying,  154 
Fergusson’s  mode  of  applying,  155 
Erichsen’s  mode  of  applying,  155 
Linear  compression,  154 
Liniments,  69 

extemporaneous  formulas  for,  70 
Lint,  44 

patent,  45 
scraped,  48 

Liquor  sodse  chlorinat.  as  a disinfectant,  11S 
Liston’s  apparatus  for  club-foot,  329 
Little’s  apparatus  for  club-fot,  327 
Local  baths,  104 
bleeding,  608 

Lonsdale’s  apparatus  for  lateral  curvature, 
306 

Loss  of  function  of  the  biceps  of  the  arm,  279 
of  the  cervical  muscles,  252 
of  the  extensor  communis  digitorum, 
277 

of  the  extensors  of  the  hand,  278 
of  the  interossei  muscles  of  the  hand, 
276 

of  the  muscles  of  the  fingers,  274 
of  the  muscles  of  the  abdomen,  254 
of  the  tibialis  anticus,  281 
of  the  sphincter  ani,  267 
of  the  extensor  muscles  of  the  legs, 
282 


Loss  of  function — 

of  the  scapular  muscles,  279  v 
of  the  peronei  muscles,  281 
of  the  ligaments  of  the  hips,  289 
of  the  ligaments  of  the  knee-joint, 
284 

of  the  uterine  ligaments,  268 
of  parts  of  the  head  and  neck,  219 
of  symmetry  of  the  pelvis,  314 
Lotions,  72 

extemporaneous  formula  for,  62 

MaisonabA’s  co^ch  for  lateral  curvature  of 
the  spine,  303 
Main  au  griffe,  276 

Maissonneuve’s  plan  of  cauterization,  584 
ecraseur,  157 
Maltese  cross,  54 

mode  of  preparing,  54 
Manner  of  opening  abscesses,  593 
Maw’s  metallic  syringe,  112 
Mayor’s  system  of  bandaging,  137 
Meche,  47 

common,  47 
linen,  47 
cotton,  47 
use  of,  47 

Mechanism  of  the  joints  of  artificial  legs.  243 
Mechanical  condition  of  the  natural  leg,  238 
Mechanical  bandages,  159 
leech,  613 

apparatus  and  bandages,  21S 
Medicated  water-dressing,  89 
pessaries.  Ill 
formulae  for,  lllj 

Mercie’s  mode  of  making  splints,  259 
Metallic  plates  as  a dressing,  50 
application  of,  50 

Metacarpal  bones,  dislocation  of,  541 
fracture  of,  434 

Mode  of  attaching  artificial  legs,  241 
of  holding  scalpel,  597 
of  making  pasteboard  splints,  259 

plaster  of  Paris  splints,  368 
of  repair  in  fracture,  350 
of  treating  loss  of  function  of  muscles, 
252 

of  arranging  spiral  springs  in  the  ankle- 
joint  of  artificial  legs,  244 
of  making  trusses,  255 
of  supporting  the  breast  with  adhesive 
strips,  141 

of  fixing  terminal  end  of  rollers,  136 
Modelling  process,  661 
Morbus  coxarius,  337 

Morgan’s  sound  for  dilating  nasal  duct,  620 
Most  convenient  length  of  arm  for  artificial 
limb,  237 
Moss,  50 

use  of,  as  a dressing,  50 
Moxa,  585 
Moxibustion,  586 

Nasal  duct,  obstruction  of,  619 
Nmvus,  154 

Ericbsens  mode  of  ligatiDg,  155 
Fergusson’s  mode  of  ligating,  155 
Needles,  43 

surgical,  43 
exploring,  43 
artery,  43 

for  twisted  suture,  659 


INDEX 


683 


Non-union  of  fracture,  352 
Nostrils,  plugging  of,  621 

removal  of  foreign  bodies  from,  635 

OAKUsr,  49 

use  of  in  gunshot  wounds,  49 
physical  characters  of,  49 
mode  of  applying,  49 
Obturator  hernia,  261 
for  the  palate,  224 
Ointments,  64 

extemporaneous  formulae  for,  66 
Olecranon,  fracture  of,  431 
Orchitis,  chronic,  treatment  of  with  adhesive 
straps,  150 
Orthopraxy,  218 
Ozone  as  a disinfectant,  119 

Pads  for  splints,  358 
Pain  in  fractures,  350 
Palate,  223 

artificial,  224 
fissure  of,  223 

Paralysis  of  the  tibialis  anticus,  281 
Patella,  dislocation  of,  556 
fracture  of,  471 
Pasteboard  splints,  359 
Pea  issue,  587 
Pellet  of  lint,  47 

mode  of  preparing,  47 
use  of.  47 

Pelvis,  dislocation  of,  547 
fracture  of,  435 

Permanganate  of  potassa  as  a disinfectant,  120 
Pessaries,  269 
common,  269 
Zwanck’s,  269 
Cloquet’s,  269 
India-rubber,  270 
Hodge’s,  271 
sponge,  271 
Bauhin’s,  272 
Prunel’s,  272 
Mayor’s,  272 
Gariel’s,  272 

supported  by  an  external  bandage,  272 
introduction  of,  273 
Phalanges,  dislocation  of,  542 
fracture  of,  535 
Phlebotomy,  600 
Physick’s  artery  forceps,  652 
Plaster,  application  of  adhesive,  to  wounds, 
657 

to  testicle,  150 
to  ulcers,  147 
isinglass,  58 
Plasters,  67 

extemporaneous  formulae  for,  67 
Pliers  for  cutting  pins,  660 
Plumasseau,  46 

mode  of  preparing,  46 
use  of,  46 

Plugging  posterior  nares,  621 
Pocket-case,  34 

Points  of  bearing  of  artificial  leg,  243 

Portable  shower  bath,  102 

Porte -caustic,  42 

Porte-moxa,  585 

Porte-meche,  42 

Posterior  curvature  of  the  neck,  292 
of  the  spine,  309 

Post’s  mode  of  treating  club-foot,  325 


Potassa  caustic,  582 
Poultices,  79 

mode  of  preparing,  79 
different  forms  of,  84 
Preternatural  mobility  in  fractures,  348 
Primitive  forms  of  Mayor’s  bandage,  138 
Prince’s  mode  of  using  elastic  cords  in  club- 
foot, 324 
Probang,  41 
Probes,  41 
simple,  41 
eyed,  41 
grooved,  41 
gunshot,  41 

Probe-pointed  bistoury,  36 
Projection  of  the  chin,  291 
Prolapsus  ani,  267 

mode  of  reduction,  297 
apparatus  for,  268 
partial,  267 
complete,  267 
uteri,  269 

Protective  bandages,  140 
Pseudarthrosis,  352 
Pulleys  for  reducing  dislocations,  50S 
Punctured  wounds,  662 
Puncturing,  592 

Purification  of  the  air  of  hospitals,  117 

Quilled  suture,  661 

Radius,  dislocation  of,  536 
fracture  of,  425 
Raw  silk,  49 

use  as  a dressing,  49 
Razor,  37 

mode  of  using,  37 

Rectum,  stricture  of,  mechanical  treatment  of, 
625 

Recamier’s  method  of  making  compression, 
150 

Recumbent  couch  for  lateral  curvature,  301 
Reef-knot,  55 

Removal  of  foreign  bodies,  630 
from  the  skin,  630 
from  the  eye,  632 
from  the  ear,  632 
from  the  nose,  635 

from  the  pharynx  and  oesophagus,  635 
from  the  larynx  and  trachea,  637 
from  the  urethra  and  bladder,  639 
from  the  vagina,  641 
from  the  rectum,  641 
Retention  of  urine,  626 
Retaining  bandages,  141 
Retractors,  52 
Ribs,  dislocations  of,  516 
fractures  of,  321 

Rigal’s  system  of  bandaging,  139 
Roller  bandages,  132 
of  linen,  132 
of  caoutchouc,  132 
of  cambric,  132 
of  calico,  132 
of  cotton,  133 

mode  of  fastening  pieces  together. 

133 

kind  used  in  Germany,  133 

mode  of  making  with  the  hands,  134 

mode  of  making  with  the  machine. 

135 

mode  of  applying,  135 


684 


INDEX. 


Roll  of  lint,  46 

mode  of  preparing,  46 
use  of,  46 
Rubefaction,  570 
Rubefacients,  571 
Rupture  of  the  tendo-Achillis,  495 

Sailor’s  or  reef-knot,  55 
Salmon  and  Ody’s  truss,  256 
Sawdust  as  a dressing  of  wounds,  50 
mode  of  using,  50 
Scalpels,  50 

single  bladed,  34 
double  bladed,  34 
different  forms,  35 
method  of  holding,  35 

Scapula,  fracture  of  body  of  coracoid  process, 
394 

Scarpa’s  shoe  for  club-foot,  326 
Scarificator,  609 
Scarification,  592 
Scissors,  surgical,  36 
straight,  36 
curved  on  the  flat,  37 
curved  on  the  edge,  37 
mode  of  using,  37 
Scraped  lint,  48 

mode  of  preparing,  48 
Scrivener’s  spasm,  53 
Scultetus'  bandage,  53 

application  of,  53 

lever  for  immobility  of  lower  jaw,  290 
Semilunar  cartilages,  displacements  of,  661 
Serrefine,  661 
Seton,  589 

Second  pieces  of  dressing,  131 
Seutin’s  mode  of  treating  fracture,  360 
scissors,  293 

Sheppard’s  dilator  for  stricture  of  the  urethra, 
153 

Shower-bath,  101 

Shoulder-joint,  dislocations  of,  523 
Simple  bandages,  131 
Sinapisms,  571 
Single  headed  roller,  134 
Sir  William  Burnett’s  disinfectant  fluid,  120 
Sling  compress,  53 
Smee’s  moulding  tablet,  364 
Snell’s  artificial  nose,  221 
Solution  of  shellac  as  an  agglutinative,  59 
Spatulas,  42 
French,  42 

Special  systems  of  bandaging,  137 
Mayor’s,  137 
Rigal’s,  139 
Spina  bifida,  228 
Spine,  curvatures  of,  297 
fractures  of,  388 
dislocation  of,  514 
Spinal  debility,  253 
Splints,  357 

of  plaster  of  Paris,  368 
Amesbury’s,  455 
Dupuytren’s,  493 
Bond’s,  428 
Boyer’s,  461 
Desault’s,  460 
Fergusson’s,  487 
Gibson’s,  Hagedorn,  440 
Hartshorne’s,  462 
Hays’,  429 
Hutchinson’s,  4S4 


Splints — 

Hamilton’s,  475 
Liston’s,  442 
Lansdale’s,  476 
Lonsdale’s,  476 
Mayo’s,  420 
Nelaton’s,  427 
Physick’s,  461 
Smith’s,  N.  R.,  467 
Wales’,  385 
Sponge,  47 

as  a dressing  to  wounds,  50 
in  compound  fracture,  50 
probang,  624 
tentr  47 

mode  of  preparing,  47 
use  of,  47 
Spongio-piline,  84 

Spring  compressor  for  ganglionic  tumors,  150 
Spring  lancet,  603 
Starch  bandages,  366 

treatment  of  fractures  with,  366 
Sternum,  fracture  of,  390 
Stitches,  application  of,  658 
Stomach  pump,  623 

Stricture  of  the  urethra,  treatment  of,  15] 
Stromeyer’s  apparatus  for  anchylosis  of  the 
elbow,  319 

foot-board  for  club-foot,  329 
Styles  for  dilating  nasal  duct,  620 
Styptic  colloid,  59 

mode  of  preparing,  59 
how  used,  60 
combinations  of,  60 
Styptics,  644 

Subcutaneous  ligature,  156 
Sulphite  of  soda  as  a disinfectant,  120 
Sulphurous  acid  as  a disinfectant,  120 
Supporting  frame  for  paralysis  of  the  lower 
extremities,  282 
Surgical  tray,  61 
wallet,  61 

Suspensory  bandages,  142 
Suspension  in  the  treatment  of  fractures  of 
the  lower  extremities,  142 
Suture,  658 

interrupted,  658 
continuous,  659 
twisted,  659 
quilled,  660 
silk,  44 
iron,  44 
lead,  44 
silver,  594 

Syme’s  absces  lancet,  41 

Talipes,  530 
valgus,  322 
varus,  330 
calcaneus,  328 
equinus,  328 

Stromeyer’s  foot-board  for,  329 
Little’s  apparatus  for,  327 
Liston’s  apparatus  for,  329 
treatment  of,  with  elastic  cords,  323 
with  adhesive  strips,  323 
Tamplin’s  apparatus  for  contracted  knee,  33o 
for  angular  curvature,  313 
for  lateral  curvature,  395 
for  posterior  curvature,  310 
Tampon,  47 

mode  of  preparing,  47 


INDEX. 


685 


Tampon — 
use  of,  47 

Tartar  emetic  ointment,  64 
Taxis,  263 

Wise’s  mode  of,  265 
Despre’s  mode  of,  265 
of  inguinal  hernia,  264 
of  crural  hernia,  264 
of  umbilical  hernia,  267 
Seutin’s  mode  of,  265 

Tavernier’s  apparatus  for  lateral  curvature, 
304 

Teeth,  artificial,  226 
Tenaculum,  40 

mode  of  using,  40 
Tenaculum-needle,  652 
Tent,  47 

mode  of  preparing,  47 
Tenotome,  600 
The  wooden-pin  leg.  242 
The  “moulding  tablet”  in  fractures,  364 
Thompson’s  bathing  apparatus,  101 
Thread  for  ligatures,  44 
for  sutures,  44 
Thumb,  dislocations  of,  542 
Tibia,  dislocation  of,  557 
fracture  of,  490 
posterior  displacement  of,  335 
Tibialis  anticus,  paralysis  of,  281 

aDd  peronei  muscles,  paralysis  of, 
281 

Todd’s  truss,  257 
Toe  contracted,  320 
fracture  of,  494 
deformity  of,  320 
hammer,  320 
Topical  remedies,  62 

mode  of  action  of,  62 
Torticollis,  294 
Tortion  of  arteries,  655 
Tourniquet,  description  of,  645 

application  of,  to  superior  extremity,  648 
to  inferior  extremity,  648 
for  aneurism,  Carte’s,  146 
Tow,  49 

use  of,  49 

Toynbee’s  syringe,  108 
Trachea,  637 

removal  of  foreign  bodies  from,  637 
Treatment  of  ununited  fracture,  352 
Trocar,  594 

Trunk,  deformities  of,  297 
Truss,  Arnott’s,  257 
Bigg’s,  257 
Bourgeand’s,  259 
Coles’,  257 
crural,  260 
Dupre’s,  259 
femoral,  260 
Hood’s,  258 
inguinal,  256 
moc-main,  259 
Salmon  and  Ody’s,  256 
Todd’s,  257 
umbilical,  261 

for  prolapse  of  the  reotum,  268 
Wickham’s,  257 
Stagner’s,  258 
Tumors,  154 

removal  of,  by  ligature,  154 


Twisted  suture,  660 
Typha  as  a dressing,  58 

Ulcers,  147 

treatment  of,  by  compression,  147 
Ulnar  fracture,  431 
Ulna  and  radius,  dislocation  of,  532 
fracture  of,  423 
Union  by  first  intention,  661 
Uniting  bandages,  42 
Ununited  fracture,  352 
Urethral  stricture,  treatment  of,  152 
Use  of  water  generally,  98 

in  surgical  diseases,  85 
Uterine  supporters,  272 
West  on,  272 

Vaccination,  594 

Valerius’  “corset-lit,”  302 

Van  Petersen’s  artificial  arm,  229 

Vapor-bath,  103 

Vapors  and  gases,  uses  of,  117 

Varus,  322 

Velpeau’s  apparatus  for  writer’s  cramp,  275 
bandage  for  supporting  pendulous  abdo- 
men, 142 

treatment  of  burns  with  adhesive  strips, 
149 

Venesection,  600 

in  external  jugular,  605 
Ventilation,  122 
of  ships,  122 
by  steam-engine,  123 
Ventilator  of  Brindejonc,  122 
Verral’s  couch  for  curvature  of  spine,  312 
Vesicants,  573 
Vesication,  573 
Vessel  for  hip-bath,  106 

Wakely’s  dilator  for  stricture  of  the  urethra, 

153 

Wales’  compressor  for  aneurism,  147 
sawdust  dressing,  51 
splint  for  fracture  of  the  lower  jaw,  384 
Warm  water-dressing,  88 
air-bath,  104 

Water  as  a surgical  dressing,  86 
Water-cushions,  98 
Water-glass,  59 

mode  of  preparing,  59 
Winder,  ivory,  for  ligature  thread,  44 
Wire  urethral  dilator,  152 
splint,  for  coxalgia,  344 
Wolf’s  jaw,  223 
Womb,  prolapse  of,  268 
Wool,  49 

physical  characters  of,  49 
use  of,  as  a dressing,  49 
Wounds,  655 

contused,  662 
gunshot,  663 
incised,  655 
punctured,  662 
mode  of  healing,  661 
method  of  dressing,  658 
Wrist-joint,  dislocation  of,  539 
contraction  of,  317 
Wrist  drop,  278 

Writer’s  or  scrivener’s  cramp,  294 
Wry-neck,  294 


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full  of  varied  and  important  matter,  of  great  interest  to  all  practitioners.  Thus,  during 
ISfifi,  contributions  have  appeared  in  its  pages  from  the  following  gentlemen* 


H.  ALLEN,  M.  D.,  Asst.  Surg.  U.  S.  A. 

JOHN  ASHHURST,  Jr.,  M.  D , Philadelphia. 
WALTER  F.  ATLEE,  M.  D.,  Philadelphia. 

E.  P.  BENNETT,  M.  D.,  Danbury,  Ct. 

BENJ.  L.  BIRD,  Jr.,  M.  D. 

J.  R.  BLACK,  M.  D.,  Newark,  0. 

ROBERT  BURNS,  M.  D.,  Fraukford,  Pa. 

WM.  0.  BALDWIN,  M.  D.,  Montgomery  Co.,  Ala. 
ROBERTS  BARTHOLOW,  M.  D.,  Cincinnati,  0. 
JOHN  G.  BIGHAM,  M.  D.,  Millersburg,  0. 

JOHN  H.  BRINT0N,  M.  D.,  Philadelphia. 

JOSEPH  CARSON,  M.  D.,  Philadelphia. 

EDWARD  T.  CASWELL,  M.  D.,  Providence,  R.  I. 
EDWARD  H.  CLARK,  M.  D.,  Boston,  Mass. 

D.  F.  CONDIE,  M.  D , Philadelphia. 

EDWARD  M.  CURTIS,  M.  D.,  Brasher  Falls,  N.  Y. 
S.  HENRY  DICKSON,  M.  D.,  Philadelphia. 

J.  C.  DALTON,  M.  D.,  New  York. 

PLINY  EARLE,  M.  D.,  Northampton,  Mass. 

D.  B.  ELSON,  M.  D.,  Cleveland,  0. 

H.  Y.  EVANS,  M.  D.,  Philadelphia. 

PAUL  F.  EVE,  M.  D.,  Nashville,  Tenn. 

AUSTIN  FLINT,  M.  D.,  New  York. 

CLARKSON  FREEMAN,  M.  D.,  Milton,  Canada  West. 
C.  C.  GRAY,  M.  D.,  Asst.  Surg.  U.  S.  A. 


W.  W.  GERHARD,  M.  D.,  Philadelphia. 

R.  GLISAN,  M.  D.,  Portland,  Oregon. 

GEO.  C.  HARLAN,  M.  D.,  Philadelphia. 

JOHN  HART,  M.  D.,  Boston,  Mass. 

EDWARD  HARTSHORNE,  M.  D.,  Philadelphia. 
PHILIP  HARVEY,  M.  D.,  Burlington,  Iowa. 

R.  E.  HAUGHTON,  M.  D.,  Richmond,  Indiana. 
ISAAC  HAYS,  M.  D.,  Philadelphia. 

H.  L.  HODGE,  M.  D.,  Philadelphia. 

J.  H.  HUTCHINSON,  M.D.,  Philadelphia. 

HENRY  HARTSHORNE,  M.  D.,  Philadelphia. 

B.  HOWARD,  M.  D.,  late  U.  S.  A. 

WM.  HUNT,  M.  D.,  Philadelphia. 

A.  REEVES  JACKSON,  M.  D.,  Strondsbnrg,  Pa. 
SAMUEL  J.  JONES,  M.  D.,  Surgeon  U.  S.  N. 
SAMUEL  JACKSON,  M.  D.,  Philadelphia. 
CHARLES  H.  JONES,  M.  D.,  Asst.  Surgeon  U.  S.  A. 
M.  KEMPF,  M.  D.,  Fairmont,  Ind. 

W.  KEMPSTER,  M.  D.,  Syracuse,  N.  Y. 

A.  W.  KING,  M.  D.,  Illinois. 

J.  J.  LEVICK,  M.D.,  Philadelphia. 

M.  CAREY  LEA,  Esq.,  Philadelphia. 

JOHN  A.  LIDELL,  M.  D.,  New  York. 

IRVING.  W.  LYON,  M.  D.,  Hartford,  CL 


* Communications  are  invited  from  gentlemen  in  all  parts  of  the  country  All  elaborate  articles  inserted 
by  the  Editor  are  paid  for  by  the  Publisher. 


Henry  C.  Lea’s  Publications — (Am.  Journ.  Med.  Sciences).  3 


H.  C.  MATHIS,  M.  D.,  Taylorsville,  Ky. 
CHARLES  M.  MATSON,  M.  D.,  Brookville,  Pa. 

R.  B.  MAURY,  M.  D.,  Port  Gibson,  Miss. 
e.  McClellan,  m.  d.,  u.  s.  a. 

RICHARD  McSHERRY,  ty.  D.,  Baltimore,  Md. 

M.  L.  MEAD,  M.  D.,  Albany,  N.  Y. 

J.  AITKEN  MEIGS,  M.  D.,  Philadelphia. 

A P.  MERRILL,  M.  D.,  New  York. 

S.  W.  MITCHELL,  M.  D.,  Philadelphia. 

W.  P.  MOON,  M.  D.,  St.  Louis. 

J.  W.  MOORMAN,  M.  D.,  Hardinsbnrg,  Ky. 
THOS.  G.  MORTON,  M.  D.,  Philadelphia. 

LOUIS  MACKALL,  Jr.,  M.  D.,  Georgetown,  D.  C. 
R.  B.  MOWRY,  M.  D.,  Allegheny  City,  Pa. 

J.  H.  PACKARD,  M.  D.,  Philadelphia. 

GEORGE  PEPPER,  M.  D.,  Philadelphia. 
WILLIAM  PEPPER,  M.D.,  Philadelphia. 

J.  S.  PRETTYMAN,  M.  D.,  Milford,  Del. 

DAVID  PRINCE,  M.  D.,  Jacksonville,  111. 

E.  R.  PEASLEE,  M.  D.,  New  York. 

DEWITT  C.  PETERS,  M.  D.,  Surgeon  U.  S.  A. 

D.  B.  St.  JOHN  ROOSA,  M.  D.,  New  York. 


A.  ROTHROCK,  M.  D.,  McVeytown,  Pa. 

W.  S.  W.  RUSCI1ENBURGER,  M.D.,  Surgeon  U.  S.  N 
J.  H.  SALISBURY,  M.  D.,  Cleveland,  0. 

ELI  D.  SARGENT,  M.  D.,  U.  S.  Navy. 

J.  W.  SHERFY,  M.D.,  Act’g  Passed  Ass’t  Surg.  U S.N. 
CHARLES  C.  SHOYER,  M.D.,  Leavenworth,  Kansas. 
ALFRED  STILLE,  M.  D.,  Philadelphia. 

CHARLES  SMART,  M.  D.,  Assist.  Surgeon  U.  S.  A. 
STEPHEN  SMITH,  M.  D.,  New  York. 

L.  H.  STEINER,  M.  D.,  Baltimore,  Md. 

W.  B.  TRULL,  M.  D.,  Asst.  Surgeon  U.  S.  V. 

J.  D.  TWINING,  M.  D.,  Act’g  Assist.  Surg.  U.  S.  A. 
JAMES  TYSON,  M.  D.,  Philadelphia. 

CLINTON  WAGNER,  M.  D.,  Assist.  Surgeon  U.  S.  A. 
J.  J.  WOODWARD,  M.  D.,  Assist.  Surgeon  U.  S.  A. 
THOS.  C.  WALTON,  M.D.,  Passed  Ass’t  Surg.  U.S  N. 
ISRAEL  B.  WASHBURN,  M.  D.,  late  Surg.  U.S. V. 
W.  A.  WETHERBY,  M.  D.,  New  York. 

H.  WILLIAMS,  M.  D,  Philadelphia. 

WM.  J.  WILSON,  M.  D.,  Macon,  Mo. 

EDWARD  WHINERY,  51.  D.,  Fort  Madison,  Iowa. 
HORATIO  C.  WOOD,  Jr.,  M.  D.,  Philadelphia. 


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THE  MEDICAL  HEWS  AHD  LIBRARY- 


4 Henry  C.  Lea’s  Publications — (Am.  Journ.  Med.  Sciences ). 


in. 

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THIRTY-TWO  ARTICLES  ON  GENERAL  QUESTIONS  IN  SURGERY. 

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SEVENTY--TWO  ARTICLES  ON  MIDWIFERY  AND  DISEASES  OF  WTOMEX  AND  CHILDREN. 

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HENRY  C.  LEA, 

Nos.  TOG  and  708  Sansom  St.,  Philadelphia,  Pa. 


Henry  C.  Lea’s  Publications — ( Dictionaries ). 


5 


TJUNGLISON  ( ROBLEY ),  M.D., 

Professor  of  Institutes  of  Medicine  in  Jefferson  Medical  College , Philadelphia. 


MEDICAL  LEXICON;  A Dictionary  op  Medical  Science:  Con- 

taming  a concise  explanation  of  the  various  Subjects  and  Terms  of  Anatomy,  Physiology, 
Pathology,  Hygiene,  Therapeutics,  Pharmacology,  Pharmacy,  Surgery,  Obstetrics,  Medical 
Jurisprudence,  and  Dentistry.  Notices  of  Climate  and  of  Mineral  Waters;  Formulae  for 
Officinal,  Empirical,  and  Dietetic  Preparations;  with  the  Accentuation  and  Etymology  of 
the  Terms,  and  the  French  and  other  Synonymes ; so  as  to  constitute  a French  as  well  as 
English  Medical  Lexicon.  Thoroughly  Revised,  and  very  greatly  Modified  and  Augmented 
In  one  very  large  and  handsome  royal  octavo  volume  of  1048  double-columned  pages,  in 
small  type;  strongly  done  up  in  extra  cloth,  $6  00  ; leather,  raised  bands,  $6  75. 

The  object  of  the  author  from  the  outset  has  not  been  to  make  the  work  a mere  lexicon  or 
dictionary  of  terms,  but  to  afford,  under  each,  a condensed  view  o J its  various  medical  relations, 
and  thus  to  render  the  work  an  epitome  of  the  existing  condition  of  medical  science.  Starting 
with  this  view,  the  immense  demand  which  has  existed  for  the  work  has  enabled  him,  in  repeated 
revisions,  to  augment  its  completeness  and  usefulness,  until  at  length  it  has  attained  the  position 
of  a recognized  and  standard  authority  wherever  the  language  is  spoken.  The  mechanical  exe- 
cution of  this  edition  will  be  found  greatly  superior  to  that  of  previous  impressions.  By  enlarging 
the  size  of  the  volume  to  a royal  octavo,  and  by  the  employment  of  a small  but  clear  type,  on 
extra  fine  paper,  the  additions  have  been  incorporated  without  materially  increasing  the  bulk  of 
the  volume,  and  the  matter  of  two  or  three  ordinary  octavos  has  been  compressed  into  the  space 
of  one  not  unhandy  for  consultation  and  reference. 


It  would  be  a work  of  supererogation  to  bestow  a 
word  of  praise  upon  this  Lexicon.  We  can  only 
wonder  at  the  labor  expended,  for  whenever  we  refer 
to  its  pages  for  information  we  are  seldom  disap- 
pointed in  finding  all  we  desire,  whether  it  be  in  ac- 
centuation, etymology,  or  definition  of  terms. — New 
York  Medical  Journal , November,  1865. 

It  would  be  mere  waste  of  words  in  us  to  express 
our  admiration  of  a work  which  is  so  universally 
and  deservedly  appreciated.  The  most  admirable 
work  of  its  kind  in  the  English  language.  As  a book 
of  reference  it  is  invaluable  to  the  medical  practi- 
tioner, and  in  every  instance  that  we  have  turned 
over  its  pages  for  information  we  have  been  charmed 
by  the  clearness  of  language  and  the  accuracy  of 
detail  with  which  each  abounds.  We  can  most  cor- 
dially and  confidently  commend  it  to  our  readers. — 
Glasgow  Medical  Journal , January,  1866. 

A work  to  which  there  is  no  equal  in  the  English 
language. — Edinburgh  Medical  Journal. 

It  is  something  more  than  a dictionary,  and  some- 
thing less  than  an  encyclopedia.  This  edition  of  the 
well-known  work  is  a great  improvement  on  its  pre- 
decessors. The  book  is  one  of  the  very  few  of  which 
it  may  be  said  with  truth  that  every  medical  mau 
should  possess  it. — London  Medical  Times , Aug.  26, 
I860. 

Few  works  of  the  class  exhibit  a grander  monument 
of  patient  research  and  of  scientific  lore.  The  extent 
of  the  sale  of  this  lexicon  is  sufficient  to  testify  to  its 
usefulness,  and  to  the  great  service  conferred  by  Dr. 
Robley  Dunglison  on  the  profession,  and  indeed  on 
others,  by  its  issue. — London  Lancet , May  13,  1865. 

The  old  edition,  which  is  now  superseded  by  the 
new,  has  been  universally  looked  upon  by  the  medi- 
cal profession  as  a work  of  immense  research  and 
great  value.  The  new  has  increased  usefulness  ; for 
medicine,  in  all  its  branches,  has  been  making  such 
progress  that  many  new  terms  and  subjects  have  re- 
cently been  introduced:  all  of  which  maybe  found 
fully  defined  in  the  present  edition.  We  know  of  no 
other  dictionary  in  the  English  language  that  can 
bear  a comparison  with  it  in  point  of  completeness  of 
subjects  and  accuracy  of  statement. — N.  Y.  Drug- 
gists' Circular , 1865. 

For  many  years  Dunglison’s  Dictionary  has  been 
the  standard  book  of  reference  with  most  practition- 
ers in  this  country,  and  we  can  certainly  commend 
this  work  to  the  renewed  confidence  and  regard  of 
our  readers. — Cincinnati  Lancet,  April,  1865. 


It  is  undoubtedly  the  most  complete  and  useful 
medical  dictionary  hitherto  published  in  this  country. 
— Chicago  Med.  Examiner , February,  1S65. 

What  we  take  to  be  decidedly  the  best  medical  dic- 
tionary in  the  English  language.  The  present  edition 
is  brought  fully  up  to  the  advanced  state  of  science. 
For  many  a long  year  “Dunglison”  has  been  at  our 
elbow,  a constant  companion  and  friend,  and  we 
greet  him  in  his  replenished  and  improved  form  with 
especial  satisfaction. — Pacific  Med.  and  Surg.  Jour- 
nal, June  27,  1S65. 

This  is,  perhaps,  the  book  of  all  others  which  the 
physician  or  surgeon  should  have  on  his  shelves.  It 
is  more  needed  at  the  present  day  than  a few  years 
back. — Canada  Med.  Journal,  July,  1865. 

It  deservedly  stands  at  the  head,  and  cannot  be 
surpassed  in  excellence. — Buffalo  Med.  and  Surg. 
Journal , April,  1865. 

We  can  sincerely  commend  Dr.  Dunglison’s  work 
as  most  thorough,  scientific,  and  accurate.  We  have 
tested  it  by  searching  its  pages  for  new  terms,  which 
have  abounded  so  much  of  late  in  medical  nomen- 
clature, and  our  search  has  been  successful  in  every 
instance.  We  have  been  particularly  struck  with  the 
fulness  of  the  synonymy  and  the  accuracy  of  the  de- 
rivation of  words.  It  is  as  necessary  a work  to  every 
enlightened  physician  as  Worcester’s  English  Dic- 
tionary is  to  every  one  who  would  keep  up  his  know- 
ledge of  the  English  tongue  to  the  standard  of  the 
present  day.  It  is,  to  our  mind,  the  most  complete 
work  of  the  kind  with  which  we  are  acquainted. — 
Boston  Med.  and  Surg.  Journal,  June  22,  1865. 

We  are  free  to  confess  that  we  know  of  no  medical 
dictionary  more  complete ; no  one  better,  if  so  well 
adapted  for  the  use  of  the  student;  no  one  that  may 
be  consulted  with  more  satisfaction  by  the  medical 
practitioner. — Am.  Jour.  Med.  Sciences,  April,  1865. 

The  value  of  the  present  edition  has  been  greatly 
enhanced  by  the  introduction  of  new  subjects  and 
terms,  and  a more  complete  etymology  and  accentua- 
tion, which  renders  the  work  not  only  satisfactory 
and  desirable,  but  indispensable  to  the  physician. — 
Chicago  Med.  Journal,  April,  1865. 

No  intelligent  member  of  the  profession  can  or  will 
be  without  it. — St.  Louis  Med.  and  Surg.  Journal, 
April,  1865. 

It  has  the  rare  merit  that  it  certainly  has  no  rival 
in  the  English  language  for  accuracy  and  extent 
references. — London  Medical  Gazette. 


JJOBLYN  ( RICHARD  D.),  M.D. 

A DICTIONARY  OF  THE  TERMS  USED  IN  MEDICINE  AND 

THE  COLLATERAL  SCIENCES.  A new  American  edition,  revised,  with  numerous 
additions,  by  Isaac  Hays,  M.D.,  Editor  of  the  “American  Journal  of  the  Medical 
Sciences.”  In  one  large  royal  12ino.  volume  of  over  500  double-columned  pages;  extra 
cloth,  $1  50  ; leather,  $2  00. 

It  is  the  best  hook  of  definitions  we  have,  and  ought  always  to  be  upon  the  student’s  table. — Souther n 
Med.  and  Surg.  Journal. 


6 


Henry  C.  Lea’s  Publications — {Manuals). 


J^EILL  {JOHN),  M.D.,  and  gMITH  {FRANCIS  G.),  31.  D., 

Prof,  of  the  Institutes  of  Medicine  in  the  Univ.  of  Penna. 

AN  ANALYTICAL  COMPENDIUM  OF  THE  YARIOUS 

BRANCHES  OF  MEDICAL  SCIENCE;  for  the  Use  and  Examination  of  Students.  A 
new  edition,  revised  and  improved.  In  one  very  large  and  handsomely  printed  royal  12mo. 
volume,  of  about  one  thousand  pages,  with  374  wood  cuts,  extra  cloth,  $4 ; strongly  bound 
in  leather,  with  raised  bands,  $4  75. 


The  Compend  of  Drs.  Neill  and  Smith  is  incompara- 
bly the  most  valuable  work  of  its  class  ever  published 
in  this  country.  Attempts  have  been  made  in  various 
quarters  to  squeeze  Anatomy,  Physiology,  Surgery, 
the  Practice  of  Medicine,  Obstetrics,  Materia  Medica, 
and  Chemistry  into  a single  manual;  but  the  opera- 
tion has  signally  failed  in  the  hands  of  all  up  to  the 
advent  of  “ Neill  and  Smith’s’ ’ volume,  which  is  quite 
a miracle  of  success.  The  outlines  of  the  whole  are 
admirably  drawn  and  illustrated,  and  the  authors 
are  eminently  entitled  to  the  grateful  consideration 
of  the  student  of  every  class. — N.  0.  Med.  and  Surg. 
Journal. 

This  popular  favorite  with  the  student  is  so  well 
known  that  it  requires  no  more  at  the  hands  of  a 
medical  editor  than  the  annunciation  of  a new  and 
improved  edition.  There  is  no  sort  of  comparison 
between  this  work  and  any  other  on  a similar  plan, 
and  for  a similar  object. — Nash.  Journ.  of  Medicine. 

There  are  but  few  students  or  practitioners  of  me- 
dicine unacquainted  with  the  former  editions  of  this 
unassuming  though  highly  instructive  work.  The 
whole  science  of  medicine  appears  to  have  been  sifted, 
as  the  gold-bearing  sands  of  El  Dorado,  and  the  pre- 
cious facts  treasured  up  in  this  little  volume.  A com- 
plete portable  library  so  condensed  that  the  student 
may  make  it  his  constant  pocket  companion. — West- 
ern Lancet. 

To  compress  the  whole  science  of  medicine  in  less 
than  1,000  pages  is  an  impossibility,  but  we  think  that 
the  book  before  us  approaches  as  near  to  it  as  is  pos- 
sible. Altogether,  it  is  the  best  of  its  class,  and  has 
met  with  a deserved  success.  As  an  elementary  text- 
book for  students,  it  has  been  useful,  and  will  con- 
tinue to  be -employed  in  the  examination  of  private 
classes,  whilst  it  will  often  be  referred  to  by  the 
country  practitioner. — Va.  Med. 1.  Journal. 


As  a handbook  for  students  it  is  invaluable,  con- 
taining in  the  most  condensed  form  the  established 
facts  and  principles  of  medicine  and  its  collateral 
sciences. — N.  H.  Journal  of  Medicine. 

In  the  rapid  course  of  lectures,  where  work  for  the 
students  is  heavy,  and  review  necessary  for  an  exa- 
mination, a compend  is  not  only  valuable,  but  it  is 
almost  a sine  qua  non.  The  one  before  us  is,  in  most 
of  the  divisions,  the  most  unexceptionable  of  all  books 
of  the  kind  that  we  know  of.  The  newest  and  sound- 
est doctrines  and  the  latest  improvements  and  dis- 
coveries are  explicitly,  though  concisely,  laid  before 
the  student.  Of  course  it  is  useless  for  us  to  recom- 
mend it  to  all  last  course  students,  but  there  is  a class 
to  whom  we  very  sincerely  commend  this  cheap  book 
as  worth  its  weight  in  silver — that  class  is  the  gradu- 
ates in  medicine  of  more  than  ten  years’  standing, 
who  have  not  studied  medicine  6ince.  They  will 
perhaps  find  out  from  it  that  the  science  is  not  ex- 
actly now  what  it  was  when  they  left  it  off. — The 
Stethoscope. 

Having  made  free  use  of  this  volume  in  our  exami- 
nations of  pupils,  we  can  speak  from  experience  in 
recommending  it  as  an  admirable  compend  for  stu- 
dents, and  especially  useful  to  preceptors  who  exam- 
ine their  pupils.  It  will  save  the  teacher  much  labor 
by  enabling  him  readily  to  recall  all  of  the  points 
upon  which  his  pupils  should  be  examined.  A work 
of  this  sort  should  be  in  the  hands  of  every  one  who 
takes  pupils  into  his  office  with  a view  of  examining 
them  ; and  this  is  unquestionably  the  best  of  its  class. 
Let  every  practitioner  who  has  pupils  provide  himself 
with  it,  and  he  will  find  the  labor  of  refreshing  his 
knowledge  so  much  facilitated  that  he  will  be  able  to 
do  justice  to  his  pupils  at  very  little  cost  of  time  or 
trouble  to  himself. — Transylvania  Med.  Journal. 


JMJDLOW  (. J.L. ),  31.  D., 

A MANUAL  OF  EXAMINATIONS  upon  Anatomy,  Physiology. 

Surgery,  Practice  of  Medicine,  Obstetrics,  Materia  Medica,  Chemistry,  Pharmacy,  and 
Therapeutics.  To  which  is  added  a Medical  Formulary.  Third  edition,  thoroughly  revised 
and  greatly  extended  and  enlarged.  With  370  illustrations.  In  one  handsome  royal 
12mo.  volume  of  816  large  pages,  extra  cloth,  §3  25;  leather,  $3  75. 


The  arrangement  of  this  volume  in  the  form  of  question  and  answer  renders  it  especially  suit 
able  for  the  office  examination  of  students,  and  for  those  preparing  for  graduation. 


We  know  of  no  better  companion  for  the  student 
during  the  hours  spent  in  the  lecture-room,  or  to  re- 
fresh, at  a glance,  his  memory  of  the  various  topics 
crammed  into  his  head  by  the  various  professors  to 
whom  he  is  compelled  to  listen. — Western  Lancet. 

As  it  embraces  the  whole  range  of  medical  studies 
it  is  necessarily  voluminous,  containing  816  large 
duodecimo  pages.  After  a somewhat  careful  exami- 
nation of  its  contents,  we  have  formed  a much  more 
favorable  opinion  of  it  than  we  are  wont  to  regard 
such  works.  Although  well  adapted  to  meet  the  wants 


of  the  student  in  preparing  for  his  final  examination, 
it  might  he  profitably  consnlted  by  the  practitioner 
also,  who  is  most  apt  to  become  rusty  in  the  very  kind 
of  details  here  given,  and  who,  amid  the  hurry  of  his 
daily  routine,  is  but  too  prone  to  neglect  the  study  of 
more  elaborate  works.  The  possession  of  a volume 
of  this  kind  might  serve  as  an  indncement  for  him  to 
seize  the  moment  of  excited  curiosity  to  inform  him- 
self on  any  subject,  and  which  is  otherwise  too  often 
allowed  to  pass  unimproved. — St.  Louis  Med.  a>id 
Surg.  Journal. 


rpANNEE  { TnO 31  AS  HAWKES),  M.D., 

A MANUAL  OF  CLINICAL  MEDICINE  AND  PHYSICAL  DIAG- 
NOSIS. Third  American,  from  the  second  enlarged  and  revised  English  edition.  To 
which  is  added  The  Code  of  Ethics  of  the  American  Medical  Association.  In  one  hand- 
some volume  12mo.  ( Preparing  for  early  ‘publication.) 

This  work,  after  undergoing  a very  thorough  revision  at  the  hands  of  the  author,  may  now  be 
expected  to  appear  shortly.  The  title  scarcely  affords  a proper  idea  of  the  range  of  subjects  em- 
braced in  the  volume,  as  it  contains  not  only  very  full  details  of  diagnostic  symptoms  properly 
classified,  but  also  a large  amount  of  information  on  matters  of  every  day  practical  importance, 
not  usually  touched  upon  in  the  systematic  works,  or  scattered  through  many  different  volumes. 


Henry  C.  Lea’s  Publications — {Anatomy). 


1 


« 

Q.RA  Y (HE NR  Y ) , F.  R.  S„ 

Lecturer  on  Anatomy  at  St.  George's  Hospital , London. 


ANATOMY,  DESCRIPTIVE  AND  SURGICAL.  The  Drawings  by 

H.  V.  Carter,  M.  D.,  late  Demonstrator  on  Anatomy  at  St.  George’s  Hospital ; the  Dissec- 
tions jointly  by  the  Author  and  Dr.  Carter.  Second  American,  from  the  second  revised 
and  improved  London  edition.  In  one  magnificent  imperial  octavo  volume,  of  over  800 
pages,  with  388  large  and  elaborate  engravings  on  wood.  Price  in  extra  cloth,  $6  00  ; 
leather,  raised  bands,  $7  00.  * 

The  author  has  endeavored  in  this  work  to  cover  a more  extended  range  of  subjects  than  is  cus- 
tomary in  the  ordinary  text-books,  by  giving  not  only  the  details  necessary  for  the  student,  but 
also  the  application  of  those  details  in  the  practice  of  medicine  and  surgery,  thus  rendering  it  both 
a guide  for  the  learner,  and  an  admirable  work  of  reference  for  the  active  practitioner.  The  en- 
gravings form  a special  feature  in  the  work,  many  of  them  being  the  size  of  nature,  nearly  all 
original,  and  having  the  names  of  the  various  parts  printed  on  the  body  of  the  cut,  in  place  of 
figures  of  reference,  with  descriptions  at  the  foot.  They  thus  form  a complete  and  splendid  series, 
which  will  greatly  assist  the  student  in  obtaining  a clear  idea  of  Anatomy,  and  will  also  serve  to 
refresh  the  memory  of  those  who  may  find  in  the  exigencies  of  practice  the  necessity  of  recalling 
the  details  of  the  dissecting  room;  while  combining,  as  it  does,  a complete  Atlas  of  Anatomy,  with 
a thorough  treatise  on  systematic,  descriptive,  and  applied  Anatomy,  the  work  will  be  found  of 
essential  use  to  all  physicians  who  receive  students  in  their  offices,  relieving  both  preceptor  and 
pupil  of  much  labor  in  laying  the  groundwork  of  a thorough  medical  education. 

Notwithstanding  its  exceedingly  low  price,  the  work  will  be  found,  in  every  detail  of  mechanical 
execution,  one  of  the  handsomest  that  has  yet  been  offered  to  the  American  profession ; while  the 
careful  scrutiny  of  a competent  anatomist  has  relieved  it  of  whatever  typographical  errors  existed 
in  the  English  edition. 


Thus  it  is  that  book  after  book  makes  the  labor  of 
the  student  easier  than  before,  and  since  we  have 
seen  Blanchard  & Lea’s  new  edition  of  Gray’s  Ana- 
tomy, certainly  the-  finest  work  of  the  kind  now  ex- 
tant, we  would  fain  hope  that  the  bugbear  of  medical 
students  will  lose  half  its  horrors,  and  this  necessary 
foundation  of  physiological  science  will  be  much  fa- 
cilitated and  advanced. — N.  O.  Med.  News. 

The  various  points  illustrated  are  marked  directly 
on  the  structure;  that  is,  whether  it  be  muscle,  pro- 
cess, artery,  nerve,  valve,  etc.  etc.— we  say  each  point 
is  distinctly  marked  by  lettered  engravings,  so  that 
the  student  perceives  at  once  each  point  described  as 
readily  as  if  pointed  out  on  the  subject  by  the  de- 
monstrator. Most  of  the  illustrations  are  thus  ren- 
dered exceedingly  satisfactory,  and  to  the  physician 
they  serve  to  refresh  the  memory  with  great  readiness 


and  with  scarce  a reference  to  the  printed  text.  The 
surgical  application  of  the  various  regions  is  also  pre- 
sented with  force  and  clearness,  impressing  upon  the 
student  at  each  step  of  his  research  all  the  important 
relations  of  the  structure  demonstrated. — Cincinnati 
Lancet. 

This  is,  we  believe,  the  handsomest  book  on  Ana- 
tomy as  yet  published  in  our  language,  and  bids  fair 
to  become  in  a short  time  the  standard  text-book  of 
our  colleges  and  studies.  Students  and  practitioners 
will  alike  appreciate  this  book.  We  predict  for  it  a 
bright  career,  and  are  fully  prepared  to  endorse  the 
statement  of  the  London  Lancet , that  “We  are  not 
acquainted  with  any  work  in  any  language  which 
can  take  equal  rank  with  the  one  before  us.”  Paper, 
printing,  binding,  all  are  excellent,  and  we  feel  that 
a grateful  profession  will  not  allow  the  publishers  to 
go  unrewarded. — Nashville  Med.  and  Surg.  Journal . 


VMITH  (HENR  Y H.),  M'.D.,  and  JJORNER  ( WILLIAM  E.),  M.D., 

Prof,  of  Surgery  in  the  Univ.  of  Penna.,  &c.  Late  Prof,  of  Anatomy  in  the  Univ.  ofPenna.,  Ac. 

AN  ANATOMICAL  ATLAS,  illustrative  of  the  Structure  of  the 

Human  Body.  In  one  volume,  large  imperial  octavo,  extra  cloth,  with  about  six  hundred 
and  fifty  beautiful  figures.  $4  50. 

The  plan  of  this  Atlas,  which  renders  it  so  pecu- 1 the  kind  that  has  yet  appeared ; and  we  must  add, 
liarly  convenient  for  the  student,  and  its  superb  ar- 1 the  very  beautiful  manner  in  which  it  is  “got  up  ” 
tistical  execution,  have  been  already  pointed  out.  We  I is  so  creditable  to  the  country  as  to  be  flattering  to 
must  congratulate  the  student  upon  the  completion  our  national  pride. — American  Medical  Journal. 
of  this  Atlas,  as  it  is  the  most  convenient  work  of  I 

JJORNER  (WILLIAM  E.),  M.D., 

SPECIAL  ANATOMY  AND  HISTOLOGY.  Eighth  edition,  exten- 
sively revised  and  modified.  In  two  large  octavo  volumes  of  over  1000  pages,  with  more 
than  300  wood-cuts ; extra  cloth,  $6  00. 


QHARPEY 

HUMAN  ANATOMY.  Revised,  with  Notes  and  Additions,  by  Joseph 

Leidy,  M.D.,  Professor  of  Anatomy  in  the  University  of  Pennsylvania.  Complete  in  two 
large  octavo  volumes,  of  about  1300  pages,  with  511  illustrations;  extra  cloth,  $6  00. 

The  very  low  price  of  this  standard  work,  and  its  completeness  in  all  departments  of  the  subject, 
should  command  for  it  a place  in  the  library  of  all  anatomical  students. 

J^LLEN  (J.  31.),  31. D. 

THE  PRACTICAL  ANATOMIST;  or,  The  Student’s  Guide  in  the 

Dissecting  Room.  With  266  illustrations.  In  one  very  handsome  royal  12mo.  volume, 
of  over  600  pages;  extra  cloth,  $2  00. 

One  of  the  most  useful  works  upon  the  subject  ever  written. — Medical  Examiner. 


( WILLIAM ),  M.D.,  and  Q RAIN  (JONES  Sf  RICHARD). 


8 


Henry  C.  Lea’s  Publications — {Anatomy). 


jyiLSON  [ERASMUS),  F.R.S. 


A SYSTEM  OF  HUMAN  ANATOMY,  General  and  Special.  A new 

and  revised  American,  from  the  last  and  enlarged  English  edition.  Edited  by  W.  H.  Go- 
brecht,  M.  D.,  Professor  of  General  and  Surgical  Anatomy  in  the  Medical  College  of  Ohio. 
Illustrated  with  three  hundred  and  ninety-seven  engravings  on  wood.  In  one  large  and 
handsome  octavo  volume,  of  over  600  large  pages;  extra  cloth,  $4  00;  leather,  $5  00. 

The  publisher  trusts  that  the  well-earned  reputation  of  this  long-established  favorite  will  be 
more  than  maintained  by  the  present  edition.  Besides  a very  thorough  revision  by  the  author,  it 
has  been  most  carefully  examined  by  the  editor,  and  the  efforts  of  both  have  been  directed  to  in- 
troducing everything  which  increased  experience  in  its  use  has  suggested  as  desirable  to  render  it 
a complete  text-book  for  those  seeking  to  obtain  or  to  renew  an  acquaintance  with  Human  Ana- 
tomy. The  amount  of  additions  which  it  has  thus  received  may  he  estimated  from  the  fact  that 
the  present  edition  contains  over  one-fourth  more  matter  than  the  last,  rendering  a smaller  type 
and  an  enlarged  page  requisite  to  keep  the  volume  within  a convenient  size.  The  author  has  not 
only  thus  added  largely  to  the  work,  but  he  has  also  made  alterations  throughout,  wherever  there 
appeared  the  opportunity  of  improving  the  arrangement  or  style,  so  as  to  present  every  fact  in  its 
most  appropriate  manner,  and  to  render  the  whole  as  clear  and  intelligible  as  possible.  The  editor 
has  exercised  the  utmost  caution  to  obtain  entire  accuracy  in  the  text,  and  has  largely  increased 
the  number  of  illustrations,  of  which  there  are  about  one  hundred  and  fifty  more  in  this  edition 
than  in  the  last,  thus  bringing  distinctly  before  the  eye  of  the  student  everything  of  interest  or 
importance. 

Y THE  SAME  A TJTHOR. 

THE  DISSECTOR’S  MANUAL;  or.  Practical  and  Surgical  Ana- 
tomy. Third  American,  from  the  last  revised  and  enlarged  English  edition.  Modified  and 
rearranged  by  William  Hdnt,  M.D.,  late  Demonstrator  of  Anatomy  in  the  University  of 
Pennsylvania.  In  one  large  and  handsome  royal  12mo.  volume,  of  582  pages,  with  154 
illustrations;  extra  cloth,  $2  00. 


TTODGES , ( RICHARD  M.),  31.  D. , 

J-  t Late  Demonstrator  of  Anatomy  in  the  Medical  Department  of  Harvard  University. 

PRACTICAL  DISSECTIONS.  Second  Edition,  thoroughly  revised.  In 

one  neat  royal  12mo.  volume,  half-bound,  $2  00.  (Just  Issued.) 

The  object  of  this  work  is  to  present  to  the  anatomical  student  a clear  and  concise  description 
of  that  which  he  is  expected  to  observe  in  an  ordinary  course  of  dissections.  The  author  has 
endeavored  to  omit  unnecessary  details,  and  to  present  the  subject  in  the  form  which  many  years? 
experience  has  shown  him  to  be  the  most  convenient  and  intelligible  to  the  student.  In  the 
revision  of  the  present  edition,  he  has  sedulously  labored  to  render  the  volume  more  worthy  of 
the  favor  with  which  it  has  heretofore  been  received. 


JJAGLISE  [JOSEPH). 

SURGICAL  ANATOMY.  By  Joseph  Maclise,  Surgeon.  In  one 

volume,  very  large  imperial  quarto;  with  6S  large  and  splendid  plates,  drawn  in  the  best 
style  and  beautifully  colored,  containing  190  figures,  many  of  them  the  size  of  life ; together 
with  copious  explanatory  letter-press.  Strongly  and  handsomely  bound  in  extra  cloth. 
Price  $14  00. 

As  no  complete  work  of  the  kind  has  heretofore  been  published  in  the  English  language,  the 
present  volume  will  supply  a want  long  felt  in  this  country  of  an  accurate  and  comprehensive 
Atlas  of  Surgical  Anatomy,  to  which  the  student  and  practitioner  can  at  all  times  refer  to  ascer- 
tain the  exact  relative  positions  of  the  various  portions  of  the  human  frame  towards  each  other 
and  to  the  surface,  as  well  as  their  abnormal  deviations.  The  importance  of  such  a work  to  the 
student,  in  the  absence  of  anatomical  material,  and  to  practitioners,  either  for  consultation  in 
emergencies  or  to  refresh  their  recollections  of  the  dissecting  room,  is  evident.  Notwithstanding 
the  large  size,  beauty  and  finish  of  the  very  numerous  illustrations,  it' will  be  observed  that  the 
price  is  so  low  as  to  place  it  within  the  reach  of  all  members  of  the  profession. 


We  know  of  no  work  on  surgical  anatomy  which 
can  compete  with  it. — Lancet. 

The  work  of  Maclise  on  surgical  anatomy  is  of  the 
highest  value.  In  some  respects  it  is  the  best  publi- 
cation of  its  kind  we  have  seen,  and  is  worthy  of  a 
place  in  the  library  of  any  medical  man,  while  the 
student  could  scarcely  make  a better  investment  than 
this. — The  Western  Journal  of  Medicine  and  Surgery. 

No  such  lithographic  illustrations  of  surgical  re- 
gions have  hitherto,  we  think,  been  given.  While 
the  operator  is  shown  every  vessel  and  nerve  where 
an  operation  is  contemplated,  the  exact  anatomist  is 


refreshed  by  those  clear  and  distinct  dissections, 
which  every  one  must  appreciate  who  has  a particle 
of  enthusiasm.  The  English  medical  press  has  quite 
exhausted  the  words  of  praise,  in  recommending  this 
admirable  treatise.  Those  who  have  any  curiosity 
to  gratify,  in  reference  to  the  perfectibility  of  the 
lithographic  art  in  delineating  the  complex  mechan- 
ism of  the  human  body,  are  invited  to  examine  our 
specimen  copy.  If  anything  will  induce  surgeons 
and  students  to  patronize  a book  of  such  rare  value 
and  everyday  importance  to  them,  it  will  be  a survey 
of  the  artistical  skill  exhibited  in  these  fac-similes  of 
nature. — Boston  Med.  and  Surg.  Journal. 


PEASLEE  [E.  R.),  31.  D., 

Professor  of  Anatomy  and  Physiology  in  Dartmouth  Med.  College,  -V.  H. 

HUMAN  HISTOLOGY,  in  its  relations  to  Anatomy,  Physiology,  and 

Pathology;  for  the  use  of  medical  students.  With  four  hundred  and  thirty-four  illustra- 
tions. In  one  handsome  octavo  volume  of  over  600  pages,  extra  cloth.  $3  75. 


Henry  C.  Lea’s  Publications — ( Physiology ). 


9 


SJARPENTER  (WILLIAM  B.),  M.D.,  F.R.S., 

Examine, r in  Physiology  and  Comparative  Anatomy  in  the  University  of  London . 


PRINCIPLES  OF  HUMAN  PHYSIOLOGY;  with  their  chief  appli- 

cations  to  Psychology,  Pathology,  Therapeutics,  Hygiene  and  Forensic  Medicine.  A new 
American  from  the  last  and  revised  London  edition.  With  nearly  three  hundred  illustrations. 
Edited,  with  additions,  by  Francis  Gurney  Smith,  M.  D.,  Professor  of  the  Institutes  of 
Medicine  in  the  University  of  Pennsylvania,  &c.  In  one  very  large  and  beautiful  octavo 
volume,  of  about  900  large  pages,  handsomely  printed ; extra  cloth,  $5  50;  leather,  raised 
bands,  $6  50. 


The  highest  compliment  that  can  be  extended  to 
this  great  work  of  Dr.  Carpenter  is  to  call  attention 
to  this,  another  new  edition,  which  the  favorable 
regard  of  the  profession  has  called  for.  Carpenter  is 
the  standard  authority  on  physiology,  and  no  physi- 
cian or  medical  student  will  regard  his  library  as 
complete  without  a copy  of  it. — Cincinnati  Med.  Ob- 
server. 

With  Dr.  Smith,  we  confidently  believe  “that  the 
present  will  more  than  sustain  the  enviable  reputa- 
tion already  attained  by  former  editions,  of  being 
one  of  the  fullest  and  most  complete  treatises  on  the 
subject  in  the  English  language.”  We  know  of  none 
from  the  pages  of  which  a satisfactory  knowledge  of 
the  physiology  of  the  human  organism  can  be  as  well 
obtained,  none  better  adapted  for  the  use  of  such  as 
take  up  the  study  of  physiology  in  its  reference  to 
the  institutes  and  practice  of  medicine. — Am.  Jour. 
Med.  Sciences. 

A complete  cyclopasdia  of  this  branch  of  science.— 
K.  Y.  Med.  Times. 


We  doubt  not  it  is  destined  to  retain  a strong  hold 
on  public  favor,  and  remain  the  favorite  text-book  in 
our  colleges. — Virginia  Medical  Journal. 

We  have  so  often  spoken  in  terms  of  high  com- 
mendation of  Dr.  Carpenter’s  elaborate  work  on  hu- 
man physiology  that,  in  announcing  a new  edition, 
it  is  unnecessary  to  add  anything  to  what  has  hereto- 
fore been  said,  and  especially  is  this  the  case  since 
every  intelligent  physician  is  as  well  aware  of  the 
character  and  merits  of  the  work  as  we  ourselves  are. 
— St.  Louis  Med.  and  Surg.  Journal. 

The  above  is  the  title  of  what  is  emphatically  the 
great  work  on  physiology ; and  we  are  conscious  that 
it  would  be  a useless  effort  to  attempt  to  add  any- 
thing to  the  reputation  of  this  invaluable  work,  and 
can  only  say  to  all  with  whom  our  opinion  has  any 
influence,  that  it  is  our  authority. — Atlanta  Med. 
Journal. 

The  greatest,  the  most  reliable,  and  the  best  book 
on  the  subject  which  we  know  of  in  the  English  lan- 
guage. — Stethoscope . 


gY  THE  SAME  AUTHOR.  

PRINCIPLES  OF  COMPARATIVE  PHYSIOLOGY.  New  Ameri- 
can, from  the  Fourth  and  Revised  London  Edition.  In  one  large  and  handsome  octavo 
volume,  with  over  three  hundred  beautiful  illustrations  Pp.  752.  Extra  cloth,  $5  00. 

As  a complete  and  condensed  treatise  on  its  extended  and  important  subject,  this  work  becomes 
a necessity  to  students  of  natural  science,  while  the  very  low  price  at  which  it  is  offered  places  it 
within  the  reaeh  of  all. 


J^Y  THE  SAME  AUTHOR. 

THE  MICROSCOPE  AND  ITS  REVELATIONS.  With  an  Appen- 
dix containing  the  Applications  of  the  Microscope  to  Clinical  Medicine,  &c.  By  F.  G. 
Ssni'H  M.  D.  Illustrated  by  four  hundred  and  thirty-four  beautiful  engravings  on  wood. 
In  one  large  and  very  handsome  octavo  volume,  of  724  pages,  extra  cloth,  $5  25. 


rpODD  (ROBERT  B.),  M.D.  F.R.S.,  and  J^OWMAN  (IF.),  F.R.S. 


THE  PHYSIOLOGICAL  ANATOMY  AND  PHYSIOLOGY  OF 

MAH.  With  about  three  hundred  large  and  beautiful  illustrations  on  wood.  Complete  in 
one  large  octavo  volume  of  950  pages,  extra  cloth.  Price  $4  75. 


The  names  of  Todd  and  Bowman  have  long  been 
familiar  to  the  student  of  physiology.  In  this  work 
we  have  the  ripe  experience  of  these  laborious  physi- 
ologists oh  every  branch  of  this  science.  They  gave 
each  subject  the  most  thorough  and  critical  examina- 
tion before  making  it  a matter  of  record.  Thus,  while 
they  advanced  tardily,  apparently,  in  their  publica- 
tion, the  work  thus  issued  was  a complete  exponent 
of  the  science  of  physiology  at  the  time  of  its  final 
appearance.  We  can,  therefore,  recommend  this 
work  as  one  of  the  most  reliable  which  the  student  or 


practitioner  can  consult  relating  to  physiology. — N. 
Y.  Journal  of  Medicine. 

To  it  the  rising  generation  of  medical  men  will 
owe,  in  great  measure,  a familiar  acquaintance  with 
all  the  chief  truths  respecting  the  healthy  structure 
and  working  of  the  frames  which  are  to  form  the 
subject  ofr  their  care.  The  possession  of  such  know- 
ledge will  do  more  to  make  sound  and  able  practi- 
tioners than  anything  else. — British  and  Foreign 
Medico- Chirurgieal  Review. 


J£IRKES  ( WILLIAM  SENHO  USE),  M.  D., 


A MANUAL  OF  PHYSIOLOGY.  A new  American  from  the  third 

and  improved  London  edition  With  two  hundred  illustrations.  In  one  large  and  hand- 
some royal  12mo.  volume.  Pp.  586.  Extra  cloth,  $2  25 ; leather,  $2  75. 

By  the  use  of  a fine  and  clear  type,  a very  large  amount  of  matter  has  been  condensed  into  a 
comparatively  small  volume,  and  at  its  exceedingly  low  price  it  will  be  found  a most  desirable 
manual  for  students  or  for  gentlemen  desirous  to  refresh  their  knowledge  of  modern  physiology. 


It  is  at  once  convenient  in  £ize,  comprehensive  in 
design,  And  concise  in  statement,  and  altogether  well 
adapted  for  the  purpose  designed. — St.  Louis  Med. 
and  Surg.  Journal. 

The  physiological  reader  will  find  it  a most  excel- 


lent guide  in  the  study  of  physiology  in  its  most  ad- 
vanced and  perfect  form.  The  author  has  shown 
himself  capable  of  giving  details  sufficiently  ample 
in  a condensed  and  concentrated  shape,  on  a science 
in  which  it  is  necessary  at  once  to  be  correct  and  not 
lengthened. — Edinburgh  Med.  and  Surg . Journal . 


10 


Henry  C.  Lea’s  Publications — (Physiology). 


T\ ALTON  (J.  C.),  M.D., 

Professor  of  Physiology  In  the  College  of  Physicians  and  Surgeons,  New  York,  &c. 

A TREATISE  ON  HUMAN  PHYSIOLOGY,  Designed  for  the  use 

of  Students  and  Practitioners  of  Medicine.  Fourth  edition,  revised,  with  nearly  three  hun- 
dred illustrations  on  wood.  In  one  very  beautiful  octavo  volume,  of  about  700  pages,  extra 
cloth,  $5  25  j leather,  $6  25.  ( Now  Ready.) 

From  the  Preface  to  the  New  Edition. 

“ The  progress  made  by  Physiology  and  the  kindred  Sciences  during  the  last  few  years  has  re- 
quired, for  the  present  edition  of  this  work,  a thorough  and  extensive  revision.  This  progress 
has  not  consisted  in  any  very  striking  single  discoveries,  nor  in  a decided  revolution  in  any  of 
the  departments  of  Physiology ; but  it  has  been  marked  by  great  activity  of  investigation  in  a 
multitude  of  different  directions,  the  combined  results  of  which  have  not  failed  to  impress  a new 
character  on  many  of  the  features  of  physiological  knowledge.  ...  In  the  revision  and 
correction  of  the  present  edition,  the  author  has  endeavored  to  incorporate  all  such  improve- 
ments in  physiological  knowledge  with  the  mass  of  the  text  in  such  a manner  as  not  essentially 
to  alter  the  structure  and  plan  of  the  work,  so  far  as  they  have  been  found  adapted  to  the  warns 
and  convenience  of  the  reader.  . . . Several  new  illustrations  are  introduced,  some  of  them 

as  additions,  others  as  improvements  or  corrections  of  the  old.  Although  all  parts  of  the  book 
have  received  more  or  less  complete  revision,  the  greatest  number  of  additions  and  changes  were 
required  in  the  Second  Section,  on  the  Physiology  of  the  Nervous  System.” 

The  reputation  which  this  work  has  acquired,  as  a compact  and  convenient  summary  of  the 
most  advanced  condition  of  human  physiology,  renders  it  only  necessary  to  state  that  the  author 
has  assiduously  labored  to  render  the  present  edition  worthy  a continuance  of  the  marked  favor 
accorded  to  previous  impressions,  and  that  every  care  has  been  bestowed  upon  the  typographical 
execution  to  make  it,  as  heretofore,  one  of  the  handsomest  productions  of  the  American  press. 
A few  notices  of  former  editions  are  subjoined. 


We  believe  we  fully  recognize  the  value  of  Draper 
and  Dunglison,  Carpenter  and  Kirkes,  and  Todd  and 
Bowman,  and  yet  we  unhesitatingly  place  Dalton  at 
the  head  of  the  list,  for  qualities  already  enumerated. 
In  the  important  feature  of  illustration,  Dalton’s  work 
is  without  a peer,  either  in  adaptedness  to  the  text, 
simplicity  and  graphicness  of  design,  or  elegance  of 
artistic  execution. — Chicago  Med.  Examiner. 

In  calling  attention  to  the  recent  publication  of  the 
third  edition  of  this  book,  it  will  only  be  necessary 
to  say  that  it  retains  all  the  merits  and  essentially  the 
satne  plan  of  the  two  former  editions,  with  which 
every  American  student  of  medicine  is  undoubtedly 
familiar.  The  distinguished  author  has  added  to  the 
text  all  the  important  discoveries  in  experimental 
physiology  and  embryology  which  have  appeared 
during  the  last  three  years. — Boston  Med.  and  Surg. 
Journal , June  30,  1S64. 

The  arrangement  of  the  work  is  excellent.  The 
facts  and  theories  put  forward  in  it  are  brought  up  to 
the  present  time.  Indeed,  it  may  be  looked  upon  as 
presenting  the  latest  views  of  physiologists  in  a con- 
densed form,  written  in  a clear,  distinct  manner,  and 
in  a style  which  makes  it  not  only  a book  of  study 
to  the  student,  or  of  reference  to  the  medical  practi- 
tioner, but  a book  which  may  be  taken  up  and  read 
with  both  pleasure  and  profit  at  any  time. — Canada 
Med.  Journal , October,  1864. 

Iu  Dr.  Dalton’s  excellent  treatise  we  have  one  of 
the  latest  contributions  of  our  American  brethren  to 
medical  science,  and  its  popularity  may  be  estimated 
by  the  fact  that  this,  the  second  edition,  follows  upon 
the  first  with  the  short  interval  of  two  years.  The 
author  has  succeeded  in  giving  his  readers  an  exceed- 
ingly accurate  and  at  the  same  time  most  readable 


rtsumt  of  the  present  condition  of  physiological 
science  ; and,  moreover,  he  has  not  been  content  with 
mere  compilation,  but  has  ably  investigated  the  func- 
tions of  the  body  for  himself,  many  of  the  original 
experiments  and  observations  being  of  the  greatest 
value. — London  Med.  Review. 

This  work,  recognized  as  a standard  text-book  by 
the  medical  schools,  and  with  which  the  members  <•:' 
the  profession  are  so  familiar,  demands  but  a brief 
notice.  Its  popularity  is  attested  by  the  rapidity 
with  which  former  editions  have  been  exhausted. — 
Chicago  Med.  Journal , April,  1S64. 

To  the  student  of  physiology,  no  work  as  yet  pub- 
lished could  be  more  satisfactory  as  a guide,  not  only 
to  a correct  knowledge  of  the  physiological  subjects 
embraced  in  its  limits,  but,  what  is  of  far  greater 
importance,  it  will  prove  the  best  teacher  of  the  inodes 
of  investigation  by  which  that  knowledge  can  be 
acquired,  and,  if  necessary,  tested. — The  Columbus 
Review  of  Med.  and  Surgery. 

Until  within  a very  recent  date,  American  works 
on  physiology  were  almost  entirely  unknown  in  Eu- 
rope, a circumstance  solely  due  to  the  fact  of  their 
being  little  else  than  crude  compilations  of  European 
works.  Within  the  last  few  years,  however,  a great 
change  has  taken  place  for  the  better,  and  our  friends 
on  the  other  side  of  the  Atlantic  can  now  boast  of 
possessing  manuals  equalled  by  few  and  excelled  by 
none  of  our  own.  In  Dr.  Dalton’s  treatise  we  are 
glad  to  find  a valuable  addition  to  physiological  lite- 
rature. With  pleasure  we  have  observed  throughout 
the  volume  proof  of  the  author  not  being  a mere 
compiler  of  the  ideas  of  others,  but  an  active  laborer 
in  the  field  of  science. — The  Brit,  and  For.  Medi-co* 
Chirurgical  Review. 


T)UNGLISON  ( ROBLEY ),  31.  D., 

•U  Professor  of  Institutes  of  Medicine  in  Jefferson  Medical  College,  Philadelphia. 

HUMAN  PHYSIOLOGY.  Eighth  edition.  Thoroughly  revised  and 

extensively  modified  and  enlarged,  with  five  hundred  and  thirty-two  illustrations.  In  twc 
large  and  handsomely  printed  octavo  volumes  of  about  1500  pages,  extra  cloth.  $7  00. 


T EH31ANN  (C.  G .) 

PHYSIOLOGICAL  CHEMISTRY.  Translated  from  the  second  edi- 
tion by  George  E.  Day,  M.  D.,  F.  R.  S.,  &c.,  edited  by  R.  E.  Rogers.  M.  B.,  Professor  of 
Chemistry  in  the  Medical  Department  of  the  University  of  Pennsylvania,  with  illustrations 
selected  from  Funke’s  Atlas  of  Physiological  Chemistry,  and  an  Appendix  of  plates.  Com- 
plete in  two  large  and  handsome  octavo  volumes,  containing  1200  pages,  with  nearly  twc 
hundred  illustrations,  extra  cloth.  $6  00. 

Dr  THE  SAME  AUTHOR.  

MANUAL  OF  CHEMICAL  PHYSIOLOGY.  Translated  from  the 

German,  with  Notes  and  Additions,  by  J.  Cheston  Morris,  M.D.,  with  an  Introductory 
Essay  on  Vital  Force,  by  Professor  Samuel  Jackson,  M.  D.,  of  the  University  of  Pennsyl- 
vania. With  illustrations  on  wood.  In  one  very  handsome  octavo  volume  of  336  pages 
extra  cloth.  $2  25. 


Henry  C.  Lea’s  Publications — ( Chemistry ).  11 


J^RANDE  ( WM . T.),  D.  C.L.,  and  J'AYLOR  (ALFRED  &),  M.D.,  F.R.S. 
CHEMISTRY.  Second  American  edition,  thoroughly  revised  by  Dr. 


Taylor.  In  one  handsome  8vo.  volume  < 
( Now  Ready.) 

A most  comprehensive  and  compact  volume.  Its 
information  is  recent,  and  is  conveyed  in  clear  lan- 
guage. Its  index  of  sixty  closely-printed  columns 
shows  with  what  care  new  discoveries  have  been 
added  to  well-known  facts. — The  Chermical  News. 

The  Handbook  in  Chemistry  of  the  Student. — 
For  clearness  of  language,  accuracy  of  description, 
extent  of  information,  and  freedom  from  pedantry 
and  mysticism,  no  other  text-book  comes  into  com- 
petition with  it. — The  Lancet. 

The  authors  set  out  with  the  definite  purpose  of 
writing  a book  which  6hall  be  intelligible  to  any 
educated  man.  Thus  conceived,  and  worked  out  in 
the  most  sturdy,  common-sense  method,  this  book 
gives  in  the  clearest  and  most  summary  method 
possible  all  the  facts  and  doctrines  of  chemistry. — 
Medical  Times. 

We  can  cordially  recommend  this  work  as  one  of 


f 764  pages,  extra  cloth,  $5  00  ; leather,  $6  00. 

the  clearest,  and  most  practical  that  can  be  put  in  the 
hands  of  the  student. — Edinburgh  Med.  Journal. 

It  abounds  in  innumerable  interesting  facts  not  to 
be  found  elsewhere ; and  from  the  masterly  manner 
in  which  every  subject  is  handled,  with  its  pleasing 
mode  of  describing  even  the  dryest  details,  it  cannot 
fail  to  prove  acceptable,  not  only  to  those  for  whom 
it  is  intended,  but  to  the  profession  at  large. — Canada 
Lancet. 

We  have  for  a long  time  felt  that  the  preparation 
of  a proper  chemical  text-book  for  students  would 
be  time  better  spent  than  in  the  invention  of  a novel 
system  of  classification  or  the  discovery  of  half  a 
dozen  new  elements  ending  in  ium.  We  believe  this 
want  has  at  last  been  satisfied  in  the  book  now  before 
us,  which  has  been  prepared  expressly  for  medical 
students  by  two  of  the  most  experienced  teachers  of 
the  science  in  England. — Boston  Med.  and  Surgical 
Journal. 


jyOWMAN  (JOHN  E.) , M.  D. 

PRACTICAL  HANDBOOK  OF  MEDICAL  CHEMISTRY. 

by  C.  L.  Bloxam,  Professor  of  Practical  Chemistry  in  King’s  College,  London. 
American,  from  the  fourth  and  revised  English  Edition, 
pp.  351,  with  numerous  illustrations,  extra  cloth.  $2  25. 


The  fourth  edition  of  this  invaluable  text-book  of 
Medical  Chemistry  was  published  in  England  in  Octo- 
ber of  the  last  year.  The  Editor  has  brought  down 
the  Handbook  to  that  date,  introducing,  as  far  as  was 
compatible  with  the  necessary  conciseness  of  6uch  a 
work,  all  the  valuable  discoveries  in  the  science 
which  have  come  to  light  since  the  previous  edition 
was  printed.  The ‘work  is  indispensable  to  every 
student  of  medicine  or  enlightened  practitioner.  It 
is  printed  in  clear  type,  and  the  illustrations  are 
numerous  and  intelligible. — Boston  Med.  and  Surg. 
Journal. 


Edited 

Fourth 

In  one  neat  volume,  royal  12mo., 

The  medical  student  and  practitioner  have  already 
appreciated  properly  this  small  manual,  in  which 
instruction  for  the  examination  and  analysis  of  the 
urine,  blood  and  other  animal  products,  both  healthy 
and  morbid,  are  accurately  given.  The  directions 
for  the  detection  of  poisons  in  organic  mixtures  and 
in  the  tissues  are  exceedingly  well  exposed  in  a con- 
cise and  simple  manner.  This  fourth  edition  has 
been  thoroughly  revised  by  the  editor,  and  brought 
up  to  the  present  state  of  practical  medical  chemistry. 
— Pacific  Med.  and  Surg.  Journal. 


THE  SAME  AUTHOR.  

INTRODDCTION  TO  PRACTICAL  CHEMISTRY,  INCLUDING 

ANALYSIS.  Fourth  American,  from  the  fifth  and  revised  London  edition.  With  numer- 
ous illustrations.  In  one  neat  vol-,  royal  12mo.,  extra  cloth.  $2  25.  (Just  Issued.) 


One  of  the  most  complete  manuals  that  has  for  a 
long  time  been  given  to  the  medicaL  student. — 
Athenaeum. 

We  regard  it  as  realizing  almost  everything  to  be 
desired  in  an  introduction  to  Practical  Chemistry. 
It  is  by  far  the  best  adapted  for  the  Chemical  student 
of  any  that  has  yet  fallen  in  our  way. — British  and 
Foreign  Medico-Chirurgical  Review. 

The  best  introductory  work  on  the  subject  with 
which  we  are  acquainted. — Edinburgh  Monthly  Jour. 

This  little  treatise,  or  manual,  is  designed  espe- 
cially for  beginners.  With  this  view  the  author  has 


l very  judiciously  simplified  his  subjects  and  illustra- 
tions as  much  as  possible,  and  presents  all  of  the 
i details  pertaining  to  chemical  analysis,  and  other 
! portions  difficult  for  beginners  to  comprehend,  in 
; such  a ctear  and  distinct  manner  as  to  remove  all 
doubt  or  difficulty.  Thus  a subject  which  is  usually 
I regarded  by  students  as  almost  beyond  their  com- 
j prehension,  is  rendered  very  easy  of  acquisition. 

! Several  valuable  tables,  a glossary,  etc.,  all  combine 
! to  render  the  work  peculiarly  adapted  to  the  wants 
of  such;  and  as  such  we  commend  it  to  them. — The 
i Western  Lancet. 


QRAHAM  (THOMAS),  F.R.S. 


THE  ELEMENTS  OF  INORGANIC  CHEMISTRY,  including  the 

Applications  of  the  Science  in  the  Arts.  New  and  much  enlarged  edition,  by  Henry 
Watts  and  Robert  Bridges,  M.  D.  Complete  in  one  large  and  handsome  octavo  volume, 
of  over  800  very  large  pages,  with  two  hundred  and  thirty-two  wood-cuts,  extra  cloth. 
$5  50. 

Part  II.,  completing  the  work  from  p.  431  to  end,  with  Index,  Title  Matter,  &c.,  may  be  had 
separate,  cloth  backs  and  paper  sides.  Price  $3  00. 


From  Prof.  B.  N.  Horsford , Harvard  College. 

It  has,  in  its  earlier  and  less  perfect  editions,  been 
familiar  to  me,  and  the  excellence  of  its  plan  and 
the  clearaess  and  completeness  of  its  discussions, 
have  long  been  my  admiration. 

No  reader  of  English  works  on  this  science  can 


afford  to  be  without  this  edition  of  Prof.  Graham's 
Elements. — Silliman’s  Journal , March,  185S. 

From  Prof.  Wolcott  Gibbs,  N.  Y.  Free  Academy. 

The  work  is  an  admirable  one  in  all  respects,  and 
its  republication  here  cannot  fail  to  exert  a positive 
influence  upon  the  progress  of  science  in  this  country. 


12  Henry  C.  Lea’s  Publications — ( Chemistry  and  Pharmacy). 


JPOWNES  {GEORGE),  Pli.  D. 

A MANUAL  OP  ELEMENTARY  CHEMISTRY;  Theoretical  and 

Practical.  With  one  hundred  and  ninety-seven  illustrations.  Edited  by  Robert  Bridges, 
M.  D.  In  one  large  royal  12mo.  volume,  offiOO  pages,  extra  cloth,  $'2  00;  leather,  62  50. 


We  know  of  no  treatise  in  the  language  so  well 
calculated  to  aid  the  student  in  becoming  familiar 
with  the  numerous  facts  in  the  intrinsic  science  on 
which  it  treats,  or  one  better  calculated  as  a text- 
book for  those  attending  Chemical  lectures.  * * * * 
The  best  text-book  on  Chemistry  that  has  issued  from 
our  press. — American  Medical  Journal. 

We  again  most  cheerfully  recommend  it  as  the 
best  text-book  for  students  in  attendance  upon  Chem- 
ical lectures  that  we  have  yet  examined. — III.  and 
Ind.  Med.  and  Surg.  Journal. 

A first-rate  work  upon  a first-rate  subject. — St. 
Louis  Med.  and  Surg.  Journal. 

No  manual  of  Chemistry  which  we  have  met 
comes  so  near  meeting  the  wants  of  the  beginner. — 
Western  Journal  of  Medicine  and  Surgery. 


We  know  of  none  within  the  same  limits  which 
has  higher  claims  to  our  confidence  as  a college  class- 
book,  both  for  accuracy  of  detail  and  scientific  ar- 
rangement.— Augusta  Medical  Journal. 

We  know  of  no  text-book  on  chemistry  that  we 
would  sooner  recommend  to  the  student  than  this 
edition  of  Prof.  Fownes’  work. — Montreal  Medical 
Chronicle. 

A new  and  revised  edition  of  one  of  the  best  elemen- 
tary works  on  chemistry  accessible  to  the  American 
and  English  student. — N.  T.  Journal  of  M&iical  and 
Collateral  Science. 

We  unhesitatingly  recommend  it  to  medical  stu- 
dents.— N.  W.  Med.  and  Surg.  Journal. 

This  is  a most  excellent  text-book  for  class  instruc- 
tion in  chemistry,  whether  for  schools  or  colleges. — 
Silliman's  Journal. 


ABEL  AND  BLOXAM’S  HANDBOOK  OF  CHEMIS- 
TRY, Theoretical,  Practical,  and  Technical.  With 
a recommendatory  Preface,  by  Dr.  Hoffman.  In 
one  large  octavo  volume  of  662  pages,  with  illus- 
trations, extra  cloth,  $4  50. 

GARDNER’S  MEDICAL  CHEMISTRY,  for  the  Use  of 
Students,  and  the  Profession.  In  one  royal  12mo. 
volume,  with  wood-cuts;  pp.  396,  extra  cloth, 
$1  00. 


KNAPP’S  TECHNOLOGY  ; or  Chemistry  Applied  to 
the  Arts,  and  to  Manufactures.  Edited,  with 
numerous  notes  and  additions,  by  Dr.  Edmund 
Ronals,  and  Dr.  Thomas  Richardson.  With  Amer- 
ican additions,  by  Prof.  Walter  R.  Johnson.  In 
two  very  handsome  octavo  volumes,  containing 
about  1000  pages,  and  500  wood  engravings,  extra 
cloth,  $6  00. 


pARRISH  (ED  WARD), 

Professor  of  Materia  Medica  in  the  Philadelphia  College  of  Pharmacy. 

A TREATISE  ON  PHARMACY.  Designed  as  a Text-Book  for  the 

Student,  and  as  a Guide  for  the  Physician  and  Pharmaceutist.  With  many  Formulae  and 
Prescriptions.  Third  Edition,  greatly  improved.  In  one  handsome  octavo  volume,  of  850 
pages,  with  several  hundred  illustrations,  extra  cloth.  $5  00. 

The  rapid  progress  made  in  the  science  and  art  of  Pharmacy,  and  the  many  changes  in  the  last 
edition  of  the  Pharmacopoeia  have  required  a very  thorough  revision  of  this  work  to  render  it 
worthy  the  continued  confidence  with  which  it  has  heretofore  been  favored.  In  effecting  this, 
many  portions  have  been  condensed,  and  every  effort  has  been  made  to  avoid  increasing  unduly 
the  bulk  of  the  volume,  yet,  notwithstanding  this,  it  will  be  found  enlarged  by  about  one  hundred 
and  fifty  pages.  The  author’s  aim  has  been  to  present  in  a clear  and  compendious  manner  every- 
thing of  value  to  the  prescriber  and  dispenser  of  medicines,  and  the  work,  it  is  hoped,  will  be  found 
more  than  ever  a complete  book  of  reference  and  text-bcrok,  indispensable  to  all  who  desire  to  keep 
on  a level  with  the  advance  of  knowledge  connected  with  their  profession. 

The  immense  amount  of  practical  information  condensed  in  its  pages  may  be  estimated  from 
the  fact  that  the  Index  contains  about  4700  items.  Under  the  head  of  Acids  there  are  312  refer- 
ences ; under  Emplastrum,  36;  Extracts,  159;  Lozenges,  25;  Mixtures,  55;  Pills,  56;  Syrups, 
131;  Tinctures,  138;  Unguentum,  57,  &o. 

We  have  examined  this  large  volume  with  a good 
deal  of  care,-  and  find  that  the  author  has  completely 
exhausted  the  subject  upon  which  he  treats  ; a more 
complete  work,  we  think,  it  would  be  impossible  to 
find.  To  the  student  of  pharmacy  the  work  is  indis- 
pensable ; indeed,  so  far  as  we  know,  it  is  the  only  one 
of  its  kind  in  existence,  and  even  to  the  physician  or 
medical  student  who  can  spare  five  dollars  to  pur- 
chase it,  we  feel  sure  the  practical  information  he 
will  obtain  will  more  than  compensate  him  for  the 
outlay. — Canada  Med.  Journal , Nov.  1S64. 

The  medical  student  and  the  practising  physician 
will  find  the  volume  of  inestimable  worth  for  study 
and  reference. — San  francisco  Med.  Press , July, 

1864. 

When  we  say  that  this  book  is  in  some  respects 
the  best  which  has  been  published  on  the  subject  in 
the  English  language  for  a great  many  years,  we  do 
not  wish  it  to  be  understood  as  very  extravagant 
praise.  In  truth,  it  is  not  so  much  the  best  as  the 
only  book. — The  London  Chemical  News. 

An  attempt  to  furnish  anything  like  an  analysis  of 
Parrish’s  very  valuable  and  elaborate  Treatise  on 
Practical  Pharmacy  would  require  more  space  than 
we  have  at  our  disposal.  This,  however,  is  not  so 
much  a matter  of  regret,  inasmuch  as  it  would  be 
difficult  to  think  of  any  point,  however  minute  and 
apparently  trivial,  connected  with  the  manipulation 
ot  pharmaceutic  substances  or  appliances  which  has 


not  been  clearly  and  carefnlly  discussed  in  this  vol- 
ume. Want  of  space  prevents  our  eniargi»g  further 
on  this  valuable  work,  and  we  must  conclude  by  a 
simple  expression  of  onr  hearty  appreciation  of  its 
merits. — Dublin  Quarterly  Jour,  of  Medical  Science, 
August,  1S64. 

We  have  in  this  able  and  elaborate  work  a fair  ex- 
position of  pharmaceutical  science  as  it  exists  in  the 
United  States  ; and  it  shows  that  our  transatlantic 
friends  have  given  the  subject  most  elaborate  con- 
sideration, and  have  brought  their  art  to  a degree  of 
perfection  which,  we  believe,  is  scarcely  to  be  sur- 
passed anywhere.  The  book  is,  of  course,  of  more 
direct  value  to  the  medicine  maker  than  to  the  physi- 
cian ; yet  Mr.  Parrish  has  not  failed  to  introduce 
matter  in  which  the  prescriber  is  quite  as  much 
interested  as  the  compounder  of  remedies.  In  con- 
clusion, we  can  only  express  onr  high  opiuion  of  the 
value  of  this  work  as  a guide  to  the  pharmaceutist, 
and  in  many  respects  to  the  physician,  not  only  in 
America,  but  in  other  parts  of  the  world. — British 
Med.  Journal , Nov.  12th,  1S64. 

The  former  editions  have  been  sufficiently  long 
before  tlie  medical  public  to  render  the  merits  of  the 
work  well  known.  It  is  certaiuly  one  of  the  most 
complete  and  valuable  works  on  practical  pharmacy 
to  which  the  student,  the  practitioner,  or  the  apothe- 
cary can  have  access. — Chicago  Medical  ExavAner, 
March,  1S64. 


Henry  C.  Lea’s  Publications — {Mat.  Med.  and  Therapeutics).  13 


QRIFFITH  ( ROBERT  E.),  M.D. 

A UNIVERSAL  FORMULARY,  Containing  the  Methods  of  Pre- 
paring and  Administering  Officinal  and  other  Medicines.  The  whole  adapted  to  Physicians 
and  Pharmaceutists.  Second  edition,  thoroughly  revised,  with  numerous  additions,  by 
PkOBEKT  P.  Thomas,  M.D.,  Professor  of  Materia  Medica  in  the  Philadelphia  College  of 
Pharmacy.  In  one  large  and  handsome  octavo  volume  of  650  pages,  double-columns. 
Extra  cloth,  $4  00 ; leather,  $5  00. 

In  this  volume,  the  Formulary  proper  occupies  over  400  double-column  pages,  and  contains 
about  5000  formulas,  among  which,  besides  those  strictly  medical,  will  be  found  numerous  valuable 
receipts  for  the  preparation  of  essences,  perfumes,  inks,  soaps,  varnishes,  <fcc.  &c.  In  addition  to 
this,  the  work  contains  a vast  amount  of  information  indispensable  for  daily  reference  by  the  prac- 
tising physician  and  apothecary,  embracing  Tables  of  Weights  and  Measures,  Specific  Gravity, 
Temperature  for  Pharmaceutical  Operations,  Hydrometrical  Equivalents,  Specific  Gravities  of  some 
of  the  Preparations  of  the  Pharmacopoeias,  Relation  between  different  Thermometrical  Scales, 
Explanation  of  Abbreviations  used  in  Formulas,  Vocabulary  of  Words  used  in  Prescriptions,  Ob- 
servations on  the  Management  of  the  Sick  Room,  Doses  of  Medicines,  Rules  for  the  Administration 
of  Medicines,  Management  of  Convalescence  and  Relapses,  Dietetic  Preparations  not  included  in 
the  Formulary,  List  of  Incompatibles,  Posological  Table,  Table  of  Pharmaceutical  Names  which 
differ  in  the  Pharmacopoeias,  Officinal  Preparations  and  Directions,  and  Poisons. 

Three  complete  and  extended  Indexes  render  the  work  especially  adapted  for  immediate  consul- 
tation. One,  of  Diseases  and  their  Remedies,  presents  under  the  head  of  each  disease  the 
remedial  agents  which  have  been  usefully  exhibited  in  it,  with  reference  to  the  formulae  containing 
them — while  another  of  Pharmaceutical  and  Botanical  Names,  and  a very  thorough  General 
Index  afford  the  means  of  obtaining  at  once  any  information  desired.  The  Formulary  itself  is 
arranged  alphabetically,  under  the  heads,  of  the  leading  constituents  of  the  prescriptions. 


This  is  one  of  the  most  useful  books  for  the  prac- 
tising, physician  which  has  been  issued  from  the  press 
of  late  years,  containing  a vast  variety  of  formulas 
for  the  safe  and  convenient  administration  of  medi- 
cines, all  arranged  upon  scientific  and  rational  prin- 
ciples, with  the  quantities  stated  in  full,  without 
signs  or  abbreviations. — Memphis  Med.  Recorder. 


We  know  of  none  in  onr  language,  or  any  other,  so 
comprehensive  in  its  details. — London  Lancet. 

One  of  the  most  complete  works  of  the  kind  in  any 
language. — Edinburgh  Med.  Journal. 

We  are  not  cognizant  of  the  existence  of  a parallel 
work. — London  Med.  Gazette. 


&TILLE  {ALFRED),  M.D., 

Professor  of  Theory  and  Practice  of  Medicine  in  the  University  of  Penna. 

THERAPEUTICS  AND  MATERIA  MEDICA;  a Systematic  Treatise 

on  the  Action  and  Uses  of  Medicinal  Agents,  including  their  Description  and  History. 
Third  edition,  revised  and  enlarged.  In  two  large  and  handsome  octavo  volumes.  ( Pre- 
paring..) 

Dr.  Stille’s  splendid  work  on  therapeutics  and  ma-  I We  have  placed  first  on  the  list  Dr.  Stille’^  great 
teria  medica. — London  Med.  Times,  April  8,  1865.  | work  on  therapeutics. — Edinburgh  Med.  Juum.,  1865. 


JfJLLIS  [BENJAMIN),  M.D. 

THE  MEDICAL  FORMULARY : being  a Collection  of  Prescriptions 

derived  from  the  writings  and  practice  of  many  of  the  most  eminent  physicians  of  America 
and  Europe.  Together  with  the  usual  Dietetic  Preparations  and  Antidotes  for  Poisons.  To 
which  is  added  an  Appendix,  on  the  Endermic  use  of  Medicines,  and  on  the  use  of  Ether 
and  Chloroform.  The  whole  accompanied  with  a few  brief  Pharmaceutic  and  Medical  Ob- 
servations. Eleventh  edition,  carefully  revised  and  much  extended  by  Robert  P.  Thomas, 
M.  D.,  Professor  of  Materia  Medica  in  the  Philadelphia  College  of  Pharmacy.  In  one 
volume  8vo.,  of  about  350  pages.  $3  00. 


We  endorse  the  favorable  opinion  which  the  book 
has  so  long  established  for  itself,  and  take  this  occa- 
sion to  commend  it  to  our  readers  as  one  of  the  con- 
venient handbooks  of  the  office  and  library. — Cin- 
cinnati Lancet , Feb.  1864. 

The  work  has  long  been  before  the  profession,  and 
its  merits  are  well  known.  The  present  edition  con- 
tains many  valuable  additions,  and  will  be  found  to 
he  an  exceedingly  convenient  and  useful  volume  for 
reference  by  the  medical  practitioner.  — Chicago 
Medical  Examiner , March,  1864. 

The  work  is  now  so  well  known,  and  has  been  so 


frequently  noticed  in  this  Journal  as  the  successive 
editions  appeared,  that  it  is  sufficient,  on  the  present 
occasion,  to  state  that  the  editor  has  introduced  into 
the  eleventh  edition  a large  amount  of  new  matter, 
derived  from  the  current  medical  and  pharmaceutical 
works,  as  well  as  a number  of  valuable  prescriptions 
furnished  from  private  sources.  A very  comprehen- 
sive and  extremely  useful  index  has  also  been  sup- 
plied, which  facilitates  reference  to  the  particular 
article  the  prescriber  may  wish  to  administer;  and 
the  language  of  the  Formulary  has  been  made  to  cor- 
respond with  the  nomenclature  of  the  new  national 
Pharmacopoeia. — Am.  Jour.  Med.  Sciences,  Jan.  1864. 


T\TJNGLISON  (ROBLEY),  M.D., 

Professor  of  Institutes  of  Medicine  in  Jefferson  Medical  College,  Philadelphia. 

GENERAL  THERAPEUTICS  AND  MATERIA  MEDICA;  adapted 

for  a Medical  Text-Book.  With  Indexes  of  Remedies  and  of  Diseases  and  their  Remedies. 
Sixth  edition,  revised  and  improved.  With  one  hundred  and  ninety-three  illustrations.  In 
two  large  and  handsomely  printed  octavo  vols.  of  about  1100  pages,  extra  cloth.  $6  50. 
T)Y  THE  SAME  AUTHOR.  \ 

NEW  REMEDIES,  WITH  FORMULAE  FOR  THEIR  PREPARA- 
TION AND  ADMINISTRATION.  Seventh  edition,  with  extensive  additions.  In  one 
very  large  octavo  volume  of  770  pages,  extra  cloth.  $4  00. 


14  Henry  C.  Lea’s  Publications — {Mat.  Med.  and  Therapeutics). 


JJ  ERE  IRA  (JONATHAN),  M.D.,  F.R.S.  and  L.S. 

MATERIA  MEDICA  AND  THERAPEUTICS;  being  an  Abridg- 

ment  of  the  late  Dr.  Pereira’s  Elements  of  Materia  Medica,  arranged  in  conformity  with 
the  British  Pharmacopoeia,  and  adapted  to  the  use  of  Medical  Practitioners,  Chemist3  and 
Druggists,  Medical  and  Pharmaceutical  Students,  &c.  By  F.  J.  Farre,  M.D.,  Senior 
Physician  to  St.  Bartholomew’s  Hospital,  and  London  Editor  of  the  British  Pharmacopoeia  : 
assisted  by  Robert  Bentley,  M.R.C.S.,  Professor  of  Materia  Medica  and  Botany  to  the 
Pharmaceutical  Society  of  Great  Britain,-  and  l^y  Robert  Warington,  F.R.S. , Chemical 
Operator  to  the  Society  of  Apothecaries.  With  numerous  additions  and  references  to  the 
United  States  Pharmacopoeia,  by  Horatio  C.  Wood,  M.D.,  Professor  of  Botany  in  the 
University  of  Pennsylvania.  In  one  large  and  handsome  octavo  volume  of  1040  closely 
printed  pages,  with  236  illustrations,  extra  cloth,  $7  00 ; leather,  raised  bands,  $8  00. 
(Just  Issued.) 


The  task  of  the  American  editor  has  evidently  been 
no  sinecure,  for  not  only  has  he  given  to  us  all  that 
is  contained  in  the  abridgment  useful  for  our  pur- 
poses, but  by  a careful  and  judicious  embodiment  of 
over  a hundred  new  remedies  has  increased  the  size 
of  the  former  work  fully  one-third,  besides  adding 
many  new  illustrations,-  some  of  which  are  original. 
We  unhesitatingly  say  that  by  so  doing  he  has  pro- 
portionately increased  the  value,  not  only  of  the  con- 
densed edition,  but  has  extended  the  applicability  of 
the  great  original,  and  has  placed  his  medical  coun- 
trymen under  lasting  obligations  to  him.  The  Ame- 
rican physician  now  has  all  that  is  needed  in  the 
shape  of  a complete  treatise  on  materia  medica,  and 
the  medical  student  has  a text-book  which,  for  prac- 
tical utility  and  intrinsic  worth,  stands  unparalleled. 
Although  of  considerable  size,  it  is  none  too  large  for 
the  purposes  for  which  it  has  been  intended,  and  every 
medical  man  should,  in  justice  to  himself,  spare  a 
place  for  it  upon  his  book-shelf,  resting  assured  that 
the  more  he  consults  it  the  better  he  will  be  satisfied 
of  its  excellence. — N.  Y.  Med.  Record , Nov.  15,  1866. 

It  will  fill  a place  which  no  other  work  can  occupy 
in  the  library  of  the  physician,  student,  and  apothe- 
cary.— Boston  Med.  and  Surg.  Journal , Nov.  S,  1866. 

We  have  here  presented,  in  a volume  of  a thousand 
pages,  that  which  we  sincerely  believe  the  best  work 
oil  materia  medica  in  the  English  language.  No  phy- 
sician, no  medical  student,  can  purchase  this  book, 
and  make  anything  like  a proper  use  of  it,  without 
being  amply  rewarded  for  his  outlay. — The  Cincin- 
nati Journal  of  Medicine , November,  1866. 

The  American  editor  can  very  justly  say,  then,  that 
“his  office  has  been  no  sinecure.”  The  result,  how- 
ever, of  the  labors  of  the  different  gentlemen  engaged 
on  the  work  has  been  to  give  us  a compendium  that 
is  admirably  adapted  for  the  wants  and  necessities  of 
the  student.  We  willingly  concede  to  the  American 
editor  that  we  have  rarely  examined  a work  that,  on 
the  whole,  is  more  carefully  and  laboriously  edited 
than  this  ; or,  we  may  add,  that  is  more  improved  in 
the  process  of  editing. — New  York  Medical  Journal , 
December,  1866. 

Of  the  many  works  on  Materia  Medica  which  hare 
appeared  since  the  issuing  of  the  British  Pharmaco- 


poeia, none  will  be  more  acceptable  to  the  student 
and  practitioner  than  the  present.  Pereira's  Materia 
Medica  had  long  ago  asserted  for  itself  the  position  of 
being  the  most  complete  work  on  the  subject  in  the 
English  language.  But  its  very  completeness  stood 
in  the  way  of  its  success.  Except  in  the  way  of  refer- 
ence, or  to  those  who  made  a special  study  of  Materia 
Medica,  Dr.  Pereira’s  work  was  too  full,  and  its  pe- 
rusal required  an  amount  of  time  which  few  had  at 
their  disposal.  Dr.  Farre  has  very  j udiciously  availed 
himself  of  the  opportunity  of  the  publication  of  the 
new  Pharmacopoeia,  by  bringing  out  an  abridged  edi- 
tion of  the  great  work.  This  edition  of  Pereira  is  by 
no  means  a mere  abridged  re-issue,  but  contains  ma- 
ny improvements,  both  in  the  descriptive  and  thera- 
peutical departments.  We  can  recommend  it  as  a 
very  excellent  and  reliable  text-book. — Edinburgh 
Med  Journal , February,  1866. 

The  reader  cannot  fail  to  be  impressed,  at  a glance, 
with  the  exceeding  value  of  this  work  as  a compend 
of  nearly  all  useful  knowledge  on  the  materia  medica. 
We  are  greatly  indebted  to  Professor  Wood  for  his 
adaptation  of  it  to  our  meridian.  Without  his  emen- 
dations and  additions  it  would  lose  much  of  its  value 
to  the  American  student.  With  them  it  is  an  Ameri- 
can book  .—Pacific  Medical  and  Surgical  Journal 
December,  1866. 

Altogether,  the  work  is  a most  valuable  addition  to 
the  literature  of  this  subject,  and  will  be  of  great  use 
to  the  practitioner  of  medicine  and  medical  student. 
The  work,  as  issued  by  the  American  publisher,  is  a 
handsome  volume  of  1030  pages,  most  amply  illus- 
trated, the  wood-cuts  being  of  superior  finish,  and 
clearly  impressed. — Canada  Med.  Journal,  Nov.  1866. 

Only  592  pages,  while  Pereira's  original  volumes 
included  2000,  and  yet  the  results  of  many  years’  ad- 
ditional research  in  pharmacology  and  therapeutics 
are  embodied  in  the  new  edition.  Unquestionably 
Dr.  Farre  has  conferred  a great  benefit  upon  medical 
students  and  practitioners.  And  in  both  respects  we 
think  he  has  acted  very  judiciously.  And  the  work 
is  now  condensed — brought  fully  into  accordance  with 
the  pharmacological  opinions  in  vogue,  and  can  be 
used  with  great  advantage  as  a handbook  for  exami- 
nations.— The  Lancet,  December,  1S65. 


rt ARSON  (JOSEPH),  M.D., 

Professor  of  Materia  Medica  and  Pharmacy  in  the  University  of  Pennsytvania,  A c. 

SYNOPSIS  OF  THE  COURSE  OF  LECTURES  ON  MATERIA 

MEDICA  AND  PHARMACY,  delivered  in  the  University  of  Pennsylvania.  With  three 
Lectures  on  the  Modus  Operandi  of  Medicines.  Fourth  and  revised  edition.  ( Just  Ready.) 


ROYLE’S  MATERIA  MEDICA  AND  THERAPEU- 
TICS ; including  the  Preparations  of  the  Pharma- 
copeias of  London,  Edinburgh,  Dublin,  and  of  the 
United  States.  With  many  new  medicines.  Edited 
by  Joseph  Cakson,  M.D.  With  ninety-eight  illus- 
trations. In  one  large  octavo  volume  of  about  700 
pages,  extra  cloth.  $3  00. 

CHRISTISON'S  DISPENSATORY;  or,  Commentary 
on  the  Pharmacopoeias  of  Great  Britain  and  the 
United  States;  comprising  the  Natural  History, 
Description,  Chemistry,  Pharmacy,  Actions,  Uses, 
and  Poses  of  the  Articles  of  the  Materia  Medica. 
Second  edition,  revised  and  improved,  with  a Sup- 
plement containing  the  most  important  New  Reme- 
dies, With  copious  additions,  and  two  hundred 
and  thirteen  large  wood-engravings.  By  R.  Eoi.es- 
feld  Griffith,  M.  D.  In  one  very  handsome  octavo 
volume  of  over  1000  pages,  extra  cloth.  $4  00. 


CARPENTER'S  PRIZE  ESSAY  ON  THE  USE  OF 
Alcoholic  Liquors  in  Health  axh  Disease.  New 
edition,  with  a Preface  by  D.  F.  Condie,  M.D..  and 
explanations  of  scientific  words.  In  one  neat  12mo. 
volume,  pp.  17S,  extra  cloth.  60  cents. 

BEALE  ON  THE  LAWS  OF  HEALTH  IN  RELATION 
to  Mind  axd  Bodt.  In  one  vol.  royal  12mo.,  extra 
cloth,  pp.  296.  SO  cents. 

De  JONGH  ON  THE  THREE  KINDS  OF  COD-LIVER 
Oil,  with  their  Chemical  and  Therapeutic  Pro- 
perties. 1 vol.  12mo.,  cloth.  75  cents. 

MAYNE’S  DISPENSATORY  AND  THERAPEUTICAL 
Remembrancer.  With  every  Practical  Formula 
contained  in  the  three  British  Pharmacopeias. 
Edited,  with  the  addition  of  the  Formuis  of  the 
U.  S.  Pharmacopeia,  by  R.  E.  Griffith,  M.  D.  In 
one  12mo.  volume,  300  pp.,  extra  doth.  75  cents. 


Henry  C.  Lea’s  Publications — ( Pathology ). 


15 


/A  ROSS  ( SAMUEL  D.),  31.  D., 

Professor  of  Surgery  in  the  Jefferson  Medical  College  of  Philadelphia. 

ELEMENTS  OP  PATHOLOGICAL  ANATOMY.  Third  edition, 

thoroughly  revised  and  greatly  improved.  In  one  large  and  very  handsome  octavo  volume 
of  nearly  800  pages,  with  about  three  hundred  and  fifty  beautiful  illustrations,  of  which  a 
•large  number  are  from  original  drawings  ; extra  cloth.  $4  00. 

The  very  beautiful  execution  of  this  valuable  work,  and  the  exceedingly  low  price  at  which  it 
is  offered,  should  command  for  it  a place  in  the  library  of  every  practitioner. 


To  the  student  of  medicine  we  would  say  that  we 
know  of  no  work  which  we  can  more  heartily  com- 
mend than  Gross’s  Pathological  Anatomy. — Southern 
Med.  and  Surg.  Journal. 

The  volume  commends  itself  to  the  medical  student ; 
tt  will  repay  a careful  perusal,  and  should  be  upon 


the  book-shelf  of  every  American  physician. — Charles- 
ton Med.  Journal. 

It  contains  much  new  matter,  and  brings  down  our 
knowledge  of  pathology  to  the  latest  period. — London 
Lancet. 


JONES  {C.  HANDFIELD ) , F.E.S.,  and  SIE  YE  KING  ( ED . H.),  31.  D., 

Assistant  Physicians  and  Lecturers  in  St.  Mary's  Hospital. 

A MANUAL  OP  PATHOLOGICAL  ANATOMY.  First  American 

edition,  revised.  With  three  hundred  and  ninety-seven  handsome  wood  engravings.  In 
one  large  and  beautifully  printed  octavo  volume  of  nearly  750  pages,  extra  cloth,  $3  50. 


Our  limited  space  alone  restrains  us  from  noticing 
more  at  length  the  various  subjects  treated  of  in 
this  interesting  work;  presenting,  as  it  does,  an  excel- 
lent summary  of  the  existing  state  of  knowledge  in 
relation  to  pathological  anatomy,  we  cannot  too 
strongly  urge  upon  the  student  the  necessity  of  a tho- 
rough acquaintance  with  its  contents. — Medical  Ex- 
aminer. 

We  have  long  had  need  of  a hand-book  of  patholo- 
gical anatomy  which  should  thoroughly  reflect  the 
present  state  of  that  science.  In  the  treatise  before 
us  this  desideratum  is  supplied.  Within  the  limits  of 
a moderate  octavo,  we  have  the  outlines  of  this  great 
department  of  medical  science  accurately  defined, 


and  the  most  recent  investigations  presented  in  suffi- 
cient detail  for  the  student  of  pathology.  We  cannot 
at  this  time  undertake  a formal  analysis  of  this  trea- 
tise, as  it  would  involve  a separate  and  lengthy 
consideration  of  nearly  every  subject  discussed  ; nor 
would  such  analysis  be  advantageous  to  the  medical 
reader.  The  work  is  of  such  a character  that  every 
physician  ought  to  obtain  it,  both  for  reference  and 
study. — N.  ¥.  Journal  of  Medicine. 

Its  importance  to  the  physician  cannot  be  too  highly 
estimated,  and  we  would  recommend  our  readers  to 
add  it  to  their  library  as  soon  as  they  conveniently 
can. — Montreal  Med.  Chronicle. 


ROKITANSKY  {CARL).  31.  D., 

Curator  of  the  Imperial  Pathological  Museum,  and  Professor  at  the  University  of  Vienna. 

A MANUAL  OF  PATHOLOGICAL  ANATOMY.  Translated  by 

W.  E.  Swaine,  Edward  Sieveking,  C.  H.  Moore,  and  G.  E.  Day.  Four  volumes  octavo, 
bound  in  two,  of  about  1200  pages,  extra  cloth.  $7  50. 


GLUGE’S  ATLAS  OF  PATHOLOGICAL  HISTOLOGY.  I SIMON'S  GENERAL  PATHOLOGY,  as  conducive  to 
Translated,  with  Notes  and  Additions,  by  Joseph  | the  Establishment  of  Rational  Principles  for  the 
Leidy,  M.  D.  In  one  volume,  very  large  imperial  I Prevention  and  Cure  of  Disease.  In  one  octavo 
quarto,  with  320  copper-plate  figures,  plain  and  volume  of  212  pages,  extra  cloth.  $1  25. 
colored,  extra  cloth.  $4  00.  I 


^yiLLIAMS  [CHARLES  J.  B.),  31.  D., 

Professor  of  Clinical  Medicine  in  University  College , London. 

PRINCIPLES  OF  MEDICINE.  An  Elementary  View  of  the  Causes, 

Nature,  Treatment,  Diagnosis,  and  Prognosis  of  Disease;  with  brief  remarks  on  Hygienics, 
or  the  preservation  of  health.  A new  American,  from  the  third  and  revised  London  edition. 


In  one  octavo  volume  of  about  500  pages, 

The  unequivocal  favor  with  which  this  work  has 
been  received  by  the  profession,  both  in  Europe  and 
America,  is  one  among  the  many  gratifying  evidences 
which  might  be  adduced  as  going  to  show  that  there 
is  a steady  progress  taking  place  in  the  science  as  well 
as  in  the  art  of  medicine.— St.  Louis  Med.  and  Surg. 
Journal. 

No  work  has  ever  achieved  or  maintained  a more 
deserved  reputation. — Virginia  Med.  and  Surg. 
Journal. 

One  of  the  best  works  on  the  subject  of  which  it 
treats  in  our  language. 

It  has  already  commended  itself  to  the  high  regard 
of  the  profession ; and  we  may  well  say  that  we 
know  of  no  single  volume  that  will  afford  the  source 
of  so  thorough  a drilling  in  the  principles  of1  practice 
as  this.  Students  and  practitioners  should  make 
themselves  intimately  familiar  with  its  teachings — 
they  will  find  their  labor  and  study  most  amply 
repaid. — Cincinnati  Med.  Observer. 

There  is  no  work  in  medical  literature  which  can 
fill  the  place  of  this  one.  It  is  the  Primer  of  the 
young  practitioner,  the  Koran  of  the  scientific  one. — 
Stethoscope. 


extra  cloth.  $3  50. 

A text-book  to  which  no  other  in  our  language  is 
comparable. — Charleston  Med.  Journal. 

The  lengthened  analysis  we  have  given  of  Dr.  Wil- 
liams’s Principles  of  Medicine  will,  we  trust,  clearly 
prove  to  our  readers  his  perfect  competency  for  the 
task  he  has  undertaken — that  of  imparting  to  the 
student,  as  well  as  to  the  more  experienced  practi- 
tioner, a knowledge  of  those  general  principles  of 
pathology  on  which  alone  a correct  practice  can  be 
founded.  The  absolute  necessity  of  such  a work 
must  be  evident  to  all  who  pretend  to  more  than 
mere  empiricism.  We  must  conclude  by  again  ex- 
pressing our  high  sense  of  the  immense  benefit  which 
Dr.  Williams  has  conferred  on  medicine  by  the  pub- 
lication of  this  work.  We  are  certain  that  in  the 
present  state  of  our  knowledge  bis  Principles  of  Medi- 
cine could  not  possibly  be  surpassed.  While  wo 
regret  the  loss  which  many  of  the  rising  generation 
of  practitioners  have  sustained  by  his  resignation  o 
the  Chair  at  University  College,  it  is  comforting  to 
feel  that  his  writings  must  long  continue  to  exert  a 
powerful  influence  on  the  practice  of  that  profession 
for  the  improvement  of  which  he  has  so  assiduously 
and  successfully  labored,  and  in  which  be  holds  so 
distinguished  a position. — London  Jour,  of  Medicine 


16 


Henry  C.  Lea’s  Publications — ( Practice  of  Medicine). 


Jf  LINT  (A  (1ST IN),  M.  D., 

J-  Professor  of  the  Principles  and  Practice  of  Medicine  in  Bellevue  Med.  College,  N.  T. 

A TREATISE  ON  THE  PRINCIPLES  AND  PRACTICE  OF 


MEDICINE ; designed  for  the  use  of  Students  and  Practitioners  of  Medicine.  Second 
edition,  revised  and  enlarged.  In  one  large  and  closely  printed  octavo  volume  of  nearly 
1000  pages;  handsome  extra  cloth,  $6  50;  or  strongly  bound  in  leather,  with  raised  bands, 
$7  50.  ( Now  Ready.) 

From  the  Preface  to  the  Second  Edition. 

Four  months  after  the  publication  of  this  treatise,  the  author  was  notified  that  a second  edition 
was  called  for.  The  speedy  exhaustion  of  the  first  edition,  unexpected  in  view  of  its  large  size, 
naturally  intensified  the  desire  to  make  the  work  still  more  acceptable  to  practitioners  and 
students  of  Medicine;  and,  notwithstanding  the  brief  period  allowed  for  a revision,  additions 
have  been  made  which,  it  is  believed,  will  enhance  the  practical  utility  of  the  volume. 


We  are  happy  in  being  able  once  more  to  commend 
this  work  to  the  students  and  practitioners  of  medicine 
who  seek  for  accurate  information  conveyed  in  lan- 
guage at  once  clear,  precise,  and  expressive. — Arner. 
Journ.  Med.  Sciences , April,  1867. 

Dr.  Flint,  who  has  been  known  in  this  country  for 
many  years,  both  as  an  author  and  teacher,  who  has 
discovered  truth,  and  pointed  it  out  clearly  and  dis- 
tinctly to  others,  investigated  the  symptoms  and  na- 
tural history  of  disease  and  recorded  its  language  and 
facts,  and  devoted  a life  of  incessant  study  and 
thought  to  the  doubtful  or  obscure  in  his  profession, 
has  at  length,  in  his  ripe  scholarship,  given  this  work 
to  the  profession  as  a crowning  gift.  If  we  have  spoken 
highly  of  its  value  to  the  profession  and  world  ; if  we 
have  said,  all  considered,  it  is  the  very  best  work 
upon  medical  practice  in  any  language;  if  we  have 
spoken  of  its  excellences  in  detail,  and  given  points 
of  special  value,  wd  have  yet  failed  to  express  in  any 
degree  our  present  estimate  of  its  value  as  a guide  in 
the  practice  of  medicine.  It  does  not  contain  too  much 
or  too  little  ; it  is  not  positive  where  doubt  should  be 
expressed,  or  hesitate  where  truth  is  known.  It  is 
philosophical  and  speculative  where  philosophy  and 
speculation  are  all  that  can  at  present  be  obtained, 
but  nothing  is  admitted  to  the  elevation  of  established 
truth,  without  the  most  thorough  investigation.  It 
is  truly  remarkable  with  what  even  hand  this  work 
has  been  written,  and  how  it  all  shows  the  most  care- 
ful thought  and  untiring  study.  We  conclude  that, 
though  it  may  yet  be  susceptible  of  improvement,  it 
still  constitutes  the  very  best  which  human  knowledge 
can  at  present  produce.  “When  knowledge  is  in- 
creased,” the  work  will  doubtless  be  again  revised; 
meanwhile  we  shall  accept  it  as  the  rule  of  practice. 
— Buffalo  Med.  and  Surg.  Journal , Feb.  1867. 

He  may  justly  feel  proud  of  the  high  honor  con- 
ferred on  him  by  the  demand  for  a second  edition  of 
his  work  in  four  months  after  the  issue  of  the  first. 
No  American  practitioner  can  afford  to  do  without 
Flint’s  Practice. — Pacific  Med.  and  Surg.  Journal , 
Feb.  1867.  ' 

Dr.  Flint’s  book  is  the  only  one  on  the  practice  of 
medicine  that  can  benefit  the  young  practitioner. — 
Nashville  Med.  Journal , Aug.  1S66. 

We  consider  the  book,  in  all  its  essentials,  as  the 
best  adapted  to  the  student  of  any  of  our  numerous 
text-books  on  this  subj  ect. — N.  Y Med.  Journ.,  Jan.  ’67. 

Its  terse  conciseness  fully  redeems  it  from  being 


ranked  among  heavy  and  common-place  works,  while 
the  unmistakable  way  in  which  Dr.  Flint  gives  his 
own  views  is  quite  refreshing,  and  far  from  common. 
It  is  a book  of  enormous  research  ; the  writer  is  evi- 
dently a man  of  observation  and  large  experience ; 
his  views  are  practically  sound  and  theoretically 
moderate,  and  we  have  no  hesitation  in  commending 
his  magnum  opus  to  our  readers. — Dublin  Medical 
Press  and  Circular , May  16,  1866. 

In  the  plan  of  the  work  and  the  treatment  of  indi- 
vidual subjects  there  is  a freshness  and  an  originality 
which  make  it  worthy  of  the  study  of  practitioners 
as  well  as  students.  It  is,  indeed,  an  admirable  book, 
and  highly  creditable  to  American  medicine.  For 
clearness  and  conciseness  in  style,  for  careful  reason- 
ing upon  what  is  known,  forlucid  distinction  between 
what  we  know  and  what  we  do  not  know,  between 
what  nature  does  in  disease  and  what  the  physician 
can  do  and  should,  for  richness  in  good  clinical  ob- 
servation, for  independence  of  statement  and  opinion 
on  great  points  of  practice,  and  for  general  sagacity 
and  good  judgment,  the  work  is  most  meritorious. 
It  is  singularly  rich  in  good  qualities,  and  free  from 
faults. — London  Lancet , June  23,  1S66. 

In  following  out  such  a plan  Dr.  Flint  has  suc- 
ceeded most  admirably,  and  gives  to  his  readers  a 
work  that  is  not  only  very  readable,  interesting, 
and  concise,  but  in  every  respect  calculated  to  meet 
the  requirements  of  professional  men  of  every  class. 
The  student  has  presented  to  him,  in  the  plainest 
possible  manner,  the  symptoms  of  disease,  the  prin- 
ciples which  should  guide  him  in  its  treatment,  and 
the  difficulties  which  have  to  be  surmounted  in  order 
to  arrive  at  a correct  diagnosis.  The  practitioner, 
besides  having  such  aids,  has  offered  to  him  the  con- 
clusion which  the  experience  of  the  professor  has 
enabled  him  to  arrive  at  in  reference  to  the  relative 
merits  of  different  therapeutical  agents,  and  different 
methods  of  treatment.  This  new  work  will  add  not 
a little  to  the  well-earned  reputation  of  Prof.  Flint  as 
a medical  teacher. — N.  Y.  Med.  Record,  April  2,  1S66. 

"We  take  pleasure  in  recommending  to  the  profession 
this  valuable  and  practical  work  on  the  practice  of 
medicine,  more  particularly  as  we  have  had  oppor- 
tunities of  appreciating  from  personal  observation 
the  author’s  preeminent  merit  as  a clinical  observer. 
This  work  is  undoubtedly  one  of  great  merit,  and  we 
feel  confident  that  it  will  have  an  extensive  circula- 
tion.— The  N.  O.  Med.  and  Surg.  Journal,  Sept.  1S66. 


T\  UNGLISON,  FORBES , TWEEDIE,  AND  CONOLLY. 

■^THE  CYCLOPAEDIA  OF  PRACTICAL  MEDICINE:  comprising 

Treatises  on  the  Nature  and  Treatment  of  Diseases,  Materia  Mediea  and  Therapeutics, 
Diseases  of  Women  and  Children,  Medical  Jurisprudence,  <fcc.  &c.  In  four  large  super-royal 
octavo  volumes,  of  3254  double-columned  pages,  strongly  and  handsomely  bound.  $15. 
This  work  contains  no  less  than  four  hundred  and  eighteen  distinct  treatises,  contributed 


by  sixty-eight  distinguished  physicians. 

The  most  complete  work  on  practical  medicine 
extant,  or  at  least  in  our  language. — Buffalo  Medical 
and  Surgical  Journal. 

For  reference,  it  is  above  all  price  to  every  practi- 
tioner.— Western  Lancet. 

One  of  the  most  valuable  medical  publications  of 


the  day.  As  a work  of  reference  it  is  invaluable. — 
Western  Journal  of  Medicirie  and  Surgery. 

It  has  been  to  us,  both  as  learner  and  teacher,  a 
work  for  ready  and  frequent  reference,  one  in  which 
modern  English  medicine  is  exhibited  in  the  most  ad- 
vantageous light. — Medical  Examiner. 


BARLOW’S  MANUAL  OF  THE  PRACTICE  OF 
MEDICINE.  With  Additions  by  D.  F.  Condie, 
M.  D.  1 vol.  Svo.,  pp.  600,  cloth.  $2  50. 


HOLLAND’S  MEDICAL  NOTES  AND  REFLEC- 
TIONS. From  the  third  and  enlarged  English  edi- 
tion. In  one  handsome  octavo  volume  of  about 
500  pages,  extra  cloth.  $3  50. 


Henry  C.  Lea’s  Publications — ( Practice  of  Medicine) 


n 


TTAR TSEORNE  {HENRY),  M.D., 

Professor  of  Hygiene  in  the  University  of  Pennsylvania. 

ESSENTIALS  OF  THE  PRINCIPLES  AND  PRACTICE  OF  MEDI- 
CINE. A handy-book  for  Students  and  Practitioners.  In  one  handsome  royal  12rno. 
volume  of  about  350  pages,  clearly  printed  on  small  type,  cloth,  $2  38 ; half  bound,  $2  63. 
(Now  Ready.') 

In  this  work  the  author  has  sought  to  present  a clear  and  condensed  view  of  the  theory  and 
practice  of  physic  in  its  most  modern  aspect,  suited  to  the  wants  of  the  student  and  to  those  of 
the  practitioner  who  desires  within  a moderate  compass  to  have  the  means  of  refreshing  his  know- 
ledge or  of  noting  the  more  important  results  of  recent  investigations.  By  careful  selection  of 
material  and  the  utmost  conciseness  of  style,  a very  large  amount  of  information  will  be  found 
embodied  in  a small  compass,  conveniently  arranged  either  for  study  or  reference. 


WA TSON  [THOMAS],  M.D.,  §-c. 

M LECTURES  ON  THE  PRINCIPLES  AND  PRACTICE  OF 

PHYSIC.  Delivered  at  King’s  College,  London.  A new  American,  from  the  last  revised 
and  enlarged  English  edition,  with  Additions,  by  D.  Francis  Condie,  M.  D.,  author  of 
“A  Practical  Treatise  on  the  Diseases  of  Children,”  &c.  With  one  hundred  and  eighty- 
five  illustrations  on  wood.  In  one  very  large  and  handsome  volume,  imperial  octavo,  of 
over  1200  closely  printed  pages  in  small  type ; extra  cloth,  $6  50  j strongly  bound  in 
leather,  with  raised  bands,  $7  50. 

Believing  this  to  be  a work  which  should  lie  on  the  table  of  every  physician,  and  be  in  the  hands 
of  every  student,  every  effort  has  been  made  to  condense  the  vast  amount  of  matter  which  it  con- 
tains within  a convenient  compass,  and  at  a very  reasonable  price,  to  place  it  within  reach  of  all. 
In  its  present  enlarged  form,  the  work  contains  the  matter  of  at  least  three  ordinary  octavos, 
rendering  it  one  of  the  cheapest  works  now  offered  to  the  American  profession,  while  its  mechani- 
cal execution  makes  it  an  exceedingly  attractive  volume. 


Confessedly,  by  the  concurrent  opinions  of  the 
highest  critical  authorities  both  of  Great  Britain  and 
this  country,  the  best  compend  of  the  principles  and 
practice  of  physic  that  has  yet  appeared. — Am.  Jour, 
of  the  Med.  Sciences. 

Commendation  of  these  lectures  would  be  only 
reiterating  the  often  recorded  opinion  of  the  profes- 
sion. By  universal  consent  the  work  ranks  among: 
the  very  best  text-books  in  our  language. — III.  and 
Ind.  Med.  and  Surg.  Journal. 

It  stands  now  confessedly  in  the  first  rank  of  the 
publications  relating  to  the  practice  of  medicine. — 
Western  Journal  of  Med.  and  Surg. 

Dr.  Watson’s  Lectures  may,  without  exaggeration, 
be  styled  a mirror  of  the  practice  of  medicine. — Cin- 
cinnati Lancet. 

We  cannot  speak  too  highly  of  this  truly  classical 
work  on  the  practice  of  medicine.  Take  it  all  in  all, 
It  is  the  very  best  of  books  of  its  kind;  equalled  by 
none  in  beauty  and  elegance  of  diction,  and  not  sur- 
passed in  the  completeness  and  comprehensiveness 
of  its  contents.  It  will  be  an  indispensable  guide  to 


the  student  in  the  acquirement  of  his  profession,  and 
no  less  worthy  of  frequent  consultation  and  reference 
by  the  most  enlightened  practitioner. — Chicago  Med. 
Jodrnal. 

Dr.  Watson’s  Lectures  have  been  so  long  known 
and  celebl-ated  for  their  rare  combination  of  intrinsic 
excellence  and  attractive  style,  that  we  need  say  no 
more  of  this  edition  than  that  it  is  the  best  work  on 
the  subject  in  the  English  language,  for  the  general 
purposes  both  of  students  and  of  practitioners — all  of 
whom  we  advise  to  possess  themselves  of  a copy,  if 
they  are  not  already  so  fortunate  as  to  have  one.— 
Boston  Medical  and  Surgical  Journal. 

Young  men  will  find  in  the  work  before  us  the 
councils  of  wisdom,  and  the  old  men  the  words  of 
comfort.  Few  men  have  succeeded  so  well  as  Dr. 
Watson  in  throwing  together  science  and  common 
sense  in  the  treatment  of  disease. — Ohio  Med.  Jouiyi. 

No  practitioner  should  be  without  the  new  edition. 
— N.  O.  Med.  News. 

This  work  is  now  truly  a cyclopiedia  of  practical 
medicine. — New  York  Journal  of  Medicine. 


DICKSON’S  ELEMENTS  OF  MEDICINE;  a Compen- 
dious View  of  Pathology  and  Therapeutics,  or  the 
History  and  Treatment  of  Diseases.  Second  edi- 
tion, revised.  1 vol.  Svo.  of  7d0  pages,  extra  cloth. 
$1  00. 

WHAT  TO  OBSERVE  AT  THE  BEDSIDE  AND  AFTER 
Death  in  Medical  Cases.  Published  under  the 
authority  of  the  London  Society  for  Medical  Obser- 


vation. From  the  second  London  edition.  1 vol. 
royal  12mo.,  extra  cloth.  $1  00. 

LAYCOCK’S  LECTURES  ON  THE  PRINCIPLES 
and  Methods  of  Medical  Observation  and  Re- 
search. For  the  use  of  advanced  students  and 
junior  practitioners.  In  one  very  neat  royal  12mo. 
volume,  extra  cloth.  $1  00. 


J^ARCLAY  {A.  W.),  M.  D. 

A MANHAL  OF  MEDICAL  DIAGNOSIS;  being  an  Analysis  of  the 

Signs  and  Symptoms  of  Disease.  Third  American  from  the  second  and  revised  London 
edition.  In  one  neat  octavo  volume  of  451  pages,  extra  cloth.  $3  50. 

A work  of  immense  practical  utility. — London  I The  book  should  be  in  the  hands  of  every  practical 
Med.  Times  and  Gazette.  | man. — Dublin  Med.  Press. 


JfULLER  ( HENRY  WILLIAM),  M.  D., 

Physician  to  St.  George's  Hospital,  London. 


ON  DISEASES  OF  THE  LUNGS  AND  AIR-PASSAGES.  Their 

Pathology,  Physical  Diagnosis,  Symptoms,  and  Treatment.  From  the  second  and  revised 
English  edition.  In  one  handsome  octavo  volume  of  about  500  pages.  ( Nearly  Ready.) 


Dr.  Fuller’s  work  on  diseases  of  the  chest  was  so 
favorably  received,  that  to  many  who  did  not  know 
the  extent  of  his  engagements,  it  was  a matter  of  won- 
der that  it  should  be  allowed  to  remain  three  years 
out  of  print.  Determined,  however,  to  improve  it, 
Dr.  Fuller  would  not  consent  to  a mere  reprint,  and 


accordingly  we  have  what  might  be  with  perfect  jus- 
tice styled  an  entirely  new  work  from  his  pen,  the 
portion  of  the  work  treating  of  the  heart  and  great 
vessels  being  excluded.  Nevertheless,  this  volume  is 
of  almost  equal  size  with  the  first. — London  Medical 
Times  and  Gazette , July  20,  1867. 


18 


Henry  C.  Lea’s  Publications — ( Practice  of  Medicine). 


TfLINT  ( A USTIN),  M.  D., 

Professor  of  the  Principles  and  Practice  of  Medicine  in  Bellevue  Hospital  Med. 1.  College , N.  7. 

A PRACTICAL  TREATISE  ON  THE  PHYSICAL  EXPLORA- 
TION OF  THE  CHEST  AND  THE  DIAGNOSIS  OF  DISEASES  AFFECTING  THE 
RESPIRATORY  ORGANS.  Second  and  revised  edition.  In  one  handsome  octavo  volume 
of  595  pages,  extra  cloth,  $4  5Q.  {Just  Issued .) 


Premising  this  observation  of  the  necessity  of  each 
student  and  practitioner  making  himself  acquainted 
■with  auscultation  and  percussion,  we  may  state  our 
honest  opinion  that  Dr.  Flint’s  treatise  is  one  of  the 
most  trustworthy  guides  which  he  can  consult.  The 
style  is  clear  and  distinct,  and  is  also  concise,  being 
free  from  that  tendency  to  over-refinement  and  unne- 
cessary minuteness  which  characterizes  many  works 
on  the  same  subject. — Dublin  Medical  Press , Feb.  6, 
.1867. 

In  the  invaluable  work  before  us,  we  have  a book 
of  facts  of  nearly  600  pages,  admirably  arranged, 
clear,  thorough,  and  lucid  on  all  points,  without  pro- 
lixity; exhausting  every  point  and  topic  touched  ; a 
monument  of  patient  and  long-continued  observation, 
which  does  credit  to  its  author,  and  reflects  honor  on 

JjY  THE  SAME  AUTHOR. 


American  medicine. — Atlanta  Med. 1.  and,  Surg.  Jour - 
nol , Feb.  1867. 

The  chapter  on  Phthisis  is  replete  with  interest ; 
and  his  remarks  on  the  diagnosis,  especially  in  the 
early  stages,  are  remarkable  for  their  acumen  and 
great  practical  value.  Dr.  Flint’s  style  is  clear  and 
elegant,  and  the  tone  of  freshness  and  originality 
which  pervades  his  whole  work  lend  an  additional 
force  to  its  thoroughly  practical  character,  which 
cannot  fail  to  obtain  for  it  a place  as  a standard  work 
on  diseases  of  the  respiratory  system. — London 
Lancet , Jan.  19,  1867. 

This  is  an  admirable  book.  Excellent  in  detail  and 
execution,  nothing  better  could  be  desired  by  the 
practitioner.  Dr.  Flint  enriches  his  subject  with 
much  solid  and  not  a little  original  observation. — 
Ranking' 8 Abstract , Jan.  1867. 


A PRACTICAL  TREATISE  OX  THE  DIAGNOSIS,  PATHOLOGY, 

AND  TREATMENT  OF  DISEASES  OF  THE  HEART.  In  one  neat  octavo  volume  of 
nearly  500  pages,  with  a plate ; extra  cloth,  S3  50. 


We  question  the  fact  of  any  recent  American  author 
in  our  profession  being  more  extensively  known,  or 
more  deservedly  esteemed  in  this  country  than  Dr. 
Flint.  We  willingly  acknowledge  his  success,  more 
particularly  in  the  volume  on  diseases  of  the  heart,  in 


making  an  extended  personal  clinical  study  available 
for  purposes  of  illustration,  in  connection  with  cases 
which  have  been  reported  by  other  trustworthy  ob- 
servers.— Brit,  and  For.  Med.-Chir.  Review.  . 


( CHAMBERS  (T.  K.),  M.  D„ 

V'  Consulting  Physician  to  St.  Mary's  Hospital,  London,  &c. 

THE  INDIGESTIONS;  or,  Diseases  of  the  Digestive  Organs  Functionally 

Treated.  In  one  handsome  octavo  volume,  extra  cloth,  $2  50.  (JYovj  Heady.) 


Associate  with  this  the  rare  faculty  which  Dr. 
Chambers  has  of  infusing  an  enthusiasm  in  his  sub- 
ject, and  we  have  in  this  little  work  all  the  elements 
which  make  it  a model  of  its  sort.  We  have  perused 
it  carefully;  have  studied  every  page;  our  interest 
in  the  subject  has  been  intensified  as  we  proceeded, 
and  we  are  enabled  to  lay  it  down  with  unqualified 
praise. — N.  Y.  Med.  Record , April  15,  1S67. 

This  is  one  of  the  most  valuable  works  which  it 
has  ever  been  our  good  fortune  to  receive. — London 
Med.  Mirror , Feb.  1867. 

It  is  in  the  combination  of  these  qualities— ^clear  and 
vivid  expression,  with  thorough  scientific  knowledge 
and  practical  skill — that  his  success  as  a teacher  or 
literary  expositor  of  the  medical  art  consists ; and  the 
volume  before  us  is  a better  illustration  than  its  au- 
thor has  yet  produced  of  the  rare  degree  in  which 
those  combined  qualities  are  at  his  command.  Next 
to  the  diseases  of  children,  there  is  no  subject  on 


which  the  young  practitioner  is  oftener  consulted,  or 
on  which  the  public  are  more  apt  to  form  their 
opinions  of  his  professional  skill,  than  the  various 
phenomena  of  indigestion.  Dr.  Chambers  comes  most 
opportunely  and  effectively  to  his  assistance.  In  fact, 
there  are  few  situations  in  which  the  commencing 
practitioner  can  place  himself  in  which  Dr.  Cham- 
bers’ conclusions  on  digestion  will  not  be  of  service. 
— London  Lancet , February  23,  1S67. 

This  elegant  volume,  by  the  author  of  “Lectures, 
chiefly  Clinical,”  has  been  our  Christmas  book,  and 
we  found  it  as  interesting  as  any  of  the  popular  an- 
nuals which  deluge  us  at  that  festive  season.  We 
hope  the  author  will  accept  as  a well-deserved  com- 
pliment the  remark,  “that,  after  all  that  has  been 
written  upon  this  subject,  we  consider  it  a thorough 
triumph  to  have  put  forth  so  instructive  a volume  on 
indigestion.” — Dublin  Medical  Press  and  Cii'cular, 
January  23,  1S67. 


J^ERNTON  ( WILLIAM),  31.  D.,  F.  R.  S. 

■LECTURES  ON  THE  DISEASES  OF  THE  STOHACH;  with  an 

Introduction  on  its  Anatomy  and  Physiology.  From  the  second  and  enlarged  London  edi- 
tion. With  illustrations  on  wood.  In  one  handsome  octavo  volume  of  about  300  pages, 
extra  cloth.  $3  25.  (Just  issued.) 


Nowhere  can  be  found  a more  full,  accurate,  plain, 
and  instructive  history  of  these  diseases,  or  more  ra- 
tional views  respecting  their  pathology  and  therapeu- 
tics.— Am.  Journ.  of  the  Med.  Sciences,  April,  1S65. 


The  most  complete  work  in  our  language  upon  the 
diagnosis  and  treatment  of  these  puzzling  and  impor- 
tant diseases. — Boston  Med.  and  Surg.  Journal,  Nov. 
1865. 


ffA BERSHON  ( 8 . O.),  3RD. 

PATHOLOGICAL  AND  PRACTICAL  OBSERVATIONS  ON  DIS- 
EASES OF  THE  ALIMENTARY  CANAL,  (ESOPHAGUS.  STOMACH.  CAECUM.  AND 
INTESTINES.  With  illustrations  on  wood.  In  one  handsome  octavo  volume  of  312 
pages,  extra  cloth.  $2  50. 


TTUDSON  (A.),  3RD..  3R  R.  I.  A., 

Physician  to  the  Meath  Hospital. 

LECTURES  ON  THE  STUDY  OF  FEYER.  In  one  vol.  8vo.  (To  be 

commenced  in  the  “Medical  News  and  Library’’  for  July,  1S67.) 


Henry  C.  Lea’s  Publications — ( Practice  of  Medicine). 


19 


T>  UMSTEAD  [FREEMAN  J.),  31.  D. , 

Lecturer  on  'Materia  Medica  and  Venereal  Diseases  at  the  Col.  of  Phys.  and  Surg .,  New  York.  &c. 

THE  PATHOLOGY  AND  TREATMENT  OF  VENEREAL  DIS- 


EASES.  Including  the  results  of  recent  investigations  upon  the  subject.  A new  and  re- 
vised edition,  with  illustrations.  In  one  large  and  handsome  octavo  volume  of  640  pages, 
extra. cloth,  $5  00.  ( Lately  Issued.) 

During  the  short  time  which  has  elapsed  since  the  appearance  of  this  work,  it  has  assumed  the 
position  of  a recognized  authority  on  the  subject  wherever  the  language  is  spoken,  and  its  transla- 
tion into  Italian  shows  that  its  reputation  is  not  confined  to  our  own  tongue.  The  singular  clear- 
ness with  which  the  modern  doctrines  of  venereal  diseases  are  set  forth  renders  it  admirably 
adapted  to  the  student,  while  the  fulness  of  its  practical  details  and  directions  as  to  treatment 


makes  it  indispensable  to  the  practitioner, 
position  universally  accorded  to  it  by  the  medical 

Well  known,  as  one  of  the  best  authorities  of  the 
present  day  on  the  subject. — British  and  For.  Med .- 
Ohirurg.  Review , April,  1866. 

A regular  store-house  of  special  information. — 
London  Lancet , Feb.  24,  1866. 

A remarkably  clear  and  full  systematic  treatise  on 
the  whole  subject. — Lond.  Med.  Times  and  Gazette. 

The  best,  completest,  fullest  monograph  on  this 
subject  in  our  language. — British  American  Journal. 

Indispensable  in  a medical  library. — Pacific  Med. 
and  Surg.  Journal. 

We  have  no  doubt  that  it  will  supersede  in  America 
every  other  treatise  on  Venereal. — San  Francisco 
Med.  Press , Oct.  1864. 

A perfect  compilation  of  all  that  is  worth  knowing 
on  venereal  diseases  in  general.  It  fills  up  a gap 
which  has  long  been  felt  in  English  medical  literature. 
— Brit . and  Foreign  Med.-Chirurg.  Review , Jan.,  ’65. 

We  have  not  met  with -any  which  60  highly  merits 


few  notices  subjoined  will  show  the  very  high 
press  of  both  hemispheres. 

our  approval  and  praise  as  the  second  edition  of  Dr. 
Bumstead’s  work. — Glasgow  Med.  Journal , Oct.  1S64. 

We  know  of  no  treatise  in  any  language  which  is 
its  equal  in  point  of  completeness  and  practical  sim- 
plicity.— Boston  Medical  and  Surgical  Journal , 
Jan.  30,  1S64. 

| The  book  is  one  which  every  practitioner  should 
I have  in  his  possession,  and,  we  may  further  say,  the 
i only\)oo\z  upon  the  subject  which  he  should  acknow- 
ledge as  competent  authority. — Buffalo  Medical  and 
Surgical  Journal,  July,  1S64. 

The  best  work  with  which  we  are  acquainted,  and 
the  most  convenient  hand-book  for  the  busy  practi- 
tioner— Cincinnati  Lancet , July,  1S64. 

The  author  has  spared  no  labor  to  make  this  edition 
worthy  of  the  reputation  acquired  by  the  last,  and  we 
believe  that  no  improvement  or  suggestion  worthy  of 
notice,  recorded  since  the  last  edition  was  published, 
has  been  left  unnoticed. — Dublin  Quarterly  Journal 
of  Medical  Science , August,  1S64. 


(1ULLERIER  [A.),  and  ~DU31STEAD  (FREEMAN  J.), 

Surgeon  to  the  Hopital  du  Midi.  AJ  Lecturer  on  Venereal  Diseases  at  the  Collegeof 

Physicians  and  Surgeons,  N.  T. 

AN  ATLAS  OF  VENEREAL  DISEASES.  Translated  and  Edited  by 

Freeman  J.  Bvmstead.  To  make  a large  imperial  4to.  volume,  with  plates  containing 
about  150  figures,  beautifully  colored,  many  of  them  the  size  of  life.  (Preparing.) 

In  charge  of  the  celebrated  Hopital  du  Midi,  where  M.  Ricord  gained  his  immense  experience, 
M.  Cullerier  is  known  as  one  of  the  most  profound  syphilographers  of  the  present  day.  This 
work  presents  the  results  of  his  observations  and  reflections  on  the  whole  round  of  venereal  acci- 
dents and  affections,  and  is  illustrated  with  a complete  series  of  colored  plates,  more  minute  and 
extensive  than  anything  of  the  kind  that  has  yet  been  laid  before  the  profession.  The  translator 
and  editor,  Dr.  Bumstead,  is  so  well  known  in  this  country  as  an  authority  on  the  subject,  and 
as  a clear  and  elegant  writer,  that  his  connection  with  the  work  is  sufficient  guarantee  that  its 
value  will  be  increased  in  passing  through  his  hands. 


BUCKLER  ON  FIBRO-BRONCHITIS  AND  RHEU- 
MATIC PNEUMONIA.  In  one  octavo  vol.,  extra 
cloth,  pp.  150.  $1  25. 

FISKE  FUND  PRIZE  ESSAYS.— LEE  ON  THE  EF- 
FECTS OF  CLIMATE  ON  TUBERCULOUS  DIS- 
EASE. AND  WARREN  ON  THE  INFLUENCE  OF 
PREGNANCY  ON  THE  DEVELOPMENT  OF  TU- 
BERCLES. Together  in  one  neat  octavo  volume, 
extra  cloth,  $1  00. 


HUGHES’  CLINICAL  INTRODUCTION  TO  AUS- 
CULTATION AND  OTHER  MODES  OF  PHYSICAL 
DIAGNOSIS.  Second  edition.  One  volume  royal 
12mo.,  extra  cloth,  pp.  304.  SI  25. 

WALSHE’S  PRACTICAL  TREATISE  ON  THE  DIS- 
EASES OF  THE  HEART  AND  GREAT  VESSELS. 
Third  American,  from  the  third  revised  and  much 
enlarged  London  edition.  In  one  handsome  octavo 
volume  of  420  pages,  extra  cloth.  $3  00. 


J^A  ROCHE  (R.),  31.  D. 

YELLOW  FEVER,  considered  in  its  Historical,  Pathological,  Etio- 
logical, and  Therapeutical  Relations.  Including  a Sketch  of  the  Disease  as  it  has  occurred 
in  Philadelphia  from  1699  to  1854,  with  an  examination  of  the  connections  between  it  and 
the  fevers  known  under  the  same  name  in  other  parts  of  temperate  as  weU  as  in  tropical 
regions.  In  two  large  and  handsome  octavo  volumes,  of  nearly  1500  pages,  extra  cloth,  §7  00. 


JjY  THE  SAME  AUTHOR.  

PNEUMONIA;  its  Supposed  Connection,  Pathological,  and  Etiological, 

with  Autumnal  Fevers,  including  an  Inquiry  into  the  Existence  and  Morbid  Agency  of 
Malaria.  In  oae  handsome  octavo  volume,  extra  cloth,  of  500  pages.  $3  00. 


TONS-  ( ROBER  T D.),  K.C.C. 

A TREATISE  ON  FEVER;  or,  Selections  from  a Course  of  Lectures 

on  Fever.  Being  part  of  a Course  of  Theory  and  Practice  of  Medicine.  In  one  neat  octavo 
volume,  of  362  pages,  extra  cloth.  $2  25. 

CLYMER  ON  FEVERS;  THEIR  DIAGNOSIS,  PA- I TODD’S  CLINICAL  LECTURES  ON  CERTAIN  ACUTE 
thology  and  Treatmext.  In  one  octavo  volume  Diseases.  In  one  neat  octavo  volume,  of  320  pages 
of  600  pages,  leather.  $1  75.  | extra  cloth.  $2  50. 


20 


Henry  C.  Lea’s  Publications — ( Practice  of  Medicine). 


JJO  DEBTS  ( WILLIAM),  31.  D., 

v Lecturer  on  Medicine  in  the  Manchester  School  of  Medicine,  &c. 

A PRACTICAL  TREATISE  OX  URINARY  AND  RENAL  DIS- 

EASES,  including  Urinary  Deposits.  Illustrated  by  numerous  cases  and  engravings.  In 
one  very  handsome  octavo  volume  of  516  pp. , extra  cloth.  $4  50.  ( Just  Issued .) 


In  carrying  out  this  design,  he  has  not  only  made 
good  use  of  his  own  practical  knowledge,  hut  has 
brought  together  from  various  sources  a vast  amount 
of  information,  some  of  which  is  not  generally  pos- 
sessed by  the  profession  in  this  country.  We  must 
now  bring  our  notice  of  this  book  to  a close,  re- 
gretting only  that  we  are  obliged  to  resist  the  temp- 
tation of  giving  further  extracts  from  it.  Dr.  Roberts 
has  already  on  several  occasions  placed  before  the 
profession  the  results  of  researches  made  by  him  on 
various  points  connected  with  the  urine,  and  had  thus 
led  us  to  expect  from  him  something  good — in  which 
expectation  we  have  been  by  no  means  disappointed. 
The  book  is,  beyond  question,  the  most  comprehen- 


sive work  on  urinary  and  renal  diseases,  considered 
in  their  strictly  practical  aspect,  that  we  possess  in 
the  English  language. — British  Medical  Journal , 
Dec.  9,  1865. 

We  have  read  this  book  with  much  satisfaction. 
It  will  take  its  place  beside  the  best  treatises  in  our 
language  upon  urinary  pathology  and  therapeutics. 
Not  the  least  of  its  merits  is  that  the  author,  unlike 
some  other  book-makers,  is  contented  to  withhold 
much  that  he  is  well  qualified  to  discuss  in  order  to 
impart  to  his  volume  such  a strictly  practical  charac- 
ter as  cannot  fail  to  render  it  popular  among  British 
readers. — London  Med.  Times  arid  Gazette , March 
17,  1868. 


** * “ Bird  on  Urinary  Deposits,”  being  for  the  present  out  of  print,  gentlemen  will  find  in  the 
above  work  a trustworthy  substitute. 


MORLAND  ON  THE  MORBID  EFFECTS  OF  THE  BLOOD  AND  URINE  (MANUALS  ON).  By  J.  W. 
RETENTION.  IN  THE  BLOOD  OF  THE  ELE-  Griffth,  G.  0.  Reese,  and  A.  Markwick.  One 
MENTS  OF  THE  URINARY  SECRETION.  In  one  I volume,  royal  12mo.,  extra  cloth,  with  plates,  pp. 
small  octavo  volume,  83  pages,  extra  cloth.  75  460.  $1  25. 

cents. 


T>UCKNILL  [J.  C.),3I.D.,  and 

•*-'  Med.  Superintendent  of  the  Devon  Lunatic  Asylum. 


T)ANIEL  H.  TUKE.31.D.. 

Visiting  Medical  Officer  to  the  York  Retreat. 


A MANUAL  OF  PSYCHOLOGICAL  MEDICINE;  containing  the 

History,  Nosology,  Description,  Statistics,  Diagnosis,  Pathology,  and  Treatment  of  In- 
sanity. With  a Plate.  In  one  handsome  octavo  volume,  of  536  pages,  extra  cloth.  S4  25. 


JfTJDD  [GEORGE),  31.  D. 

ON  DISEASES  OF  THE  LIYER.  Third  American,  from  the  third 

and  enlarged  London  edition.  In  one  very  handsome  octavo  volume,  extra  cloth,  with  four 
beautifully  colored  plates,  and  numerous  wood-cuts.  pp.  500.  $4  00. 


TONES  [C.  HANDFIELD),  31.  D., 

Physician  to  St.  Mary's  Hospital , &c. 

CLINICAL  OBSERVATIONS  ON  FUNCTIONAL  XERYOUS 

DISORDERS.  In  one  handsome  octavo  volume  of  348  pages,  extra  cloth,  $3  25. 
( Now  Ready.) 

The  wide  scope  of  the  treatise,  and  its  practical  character,  as  illustrated  by  the  large  number 
of  cases  reported  in  detail  by  the  author,  can  hardly  fail  to  render  it  exceedingly  valuable  to 
the  profession. 

HARRISON’S  ESSAY  TOWARDS  A CORRECT 
THEORY  OF  THE  NERVOUS  SYSTEM.  In  one 
octavo  volume  of  292  pp.  $1  50. 

SOLLY  ON  THE  HUMAN  BRAIN;  its  Structure, 

gMITR  [ED  WARD),  31.  D. 

CONSUMPTION;  ITS  EARLY  AND  REMEDIABLE  STAGES.  In 

one  neat  octavo  volume  of  254  pages,  extra  cloth.  $2  25. 

QALTER  (R.  H.),  M.D. 

ASTHMA;  its  Pathology,  Causes,  Consequences,  and  Treatment.  In 

one  volume,  octavo,  extra  cloth.  $2  50. 

QLADE  [D.  D.),  31.  D. 

DIPHTHERIA;  its  Nature  and  Treatment,  with  an  account  of  the  His- 
tory of  its  Prevalence  in  various  Countries.  Second  and  revised  edition.  In  one  neat 
royal  12mo.  volume,  extra  cloth.  $1  25.  (Just  issued.)  » 

L LEM  AND  AND  WILSON. 

A PRACTICAL  TREATISE  ON  THE  CAUSES.  SYMPTOMS. 

AND  TREATMENT  OF  SPERMATORRHCEA.  By  M.  LaLLemand.  Translated  and 

edited  by  Henry  J.  McDougall.  Fifth  American  edition.  To  which  is  added ON 

DISEASES  OF  THE  VESICULA3  SEMINALES,  and  their  associated  organs.  With 
special  reference  to  the  Morbid  Seoretions  of  the  Prostatic  and  Urethral  Mucous  Membrane. 
By  Marris  Wilson,  M.D.  In  one  neat  octavo  volume,  of  about  400  pp.,  extra  cloth,  §2  75. 


Physiology,  and  Diseases.  From  the  Second  and 
much  enlarged  London  edition.  In  one  octavo 
volume  of  500  pages,  with  120  wood-cuts;  extra 
cloth.  $2  50. 


Henry  C.  Lea’s  Publications — (Diseases  of  the  Skin). 


21 


^yiLSON  ( EE  ASM  US),  F.  E.  S., 

ON  DISEASES  OF  THE  SKIN.  The  sixth  American,  from  the  fifth 

and  enlarged  English  edition.  In  one  large  octavo  volume  of  nearly  700  pages,  extra 
cloth.  $4  50.  Also— 

A SERIES  OF  PLATES  ILLUSTRATING  “WILSON  ON  DIS- 

EASES  OF  THE  SKIN;”  consisting  of  twenty  beautifully  executed  plates,  of  which  thir- 
teen are  exquisitely  colored,  presenting  the  Normal  Anatomy  and  Pathology  of  the  Skin, 
and  embracing  accurate  representations  of  about  one  hundred  varieties  of  disease,  most  of 
them  the  size  of  nature.  Price,  in  extra  cloth,  $5  50. 

Also,  the  Text  and  Plates,  bound  in  one  handsome  volume,  extra  cloth.  Price  $9  50. 

This  classical  work  has  for  twenty  years  occupied  the  position  of  the  leading  authority  on  cuta- 
neous diseases  in  the  English  language,  and  the  industry  of  the  author  keeps  it  on  a level  with  the 
advance  of  science,  in  the  frequent  revisions  which  it  receives  at  his  hands.  The  large  size  of  the 
volume  enables  him  to  enter  thoroughly  into  detail  on  all  the  subjects  embraced  in  it,  while  its 
very  moderate  price  places  it  within  the  reach  of  every  one  interested  in  this  department  of  practice. 


Such  a work  as  the  one  before  us  is  a most  capital 
and  acceptable  help.  Mr.  Wilson  has  long  been  held 
as  high  authority  in  this  department  of  medicine,  and 
his  book  on  diseases  of  the  skin  has  long  been  re- 
garded as  one  of  the  best  text-books  extant  on  the 
subject.  The  present  edition  is  carefully  prepared, 
and  brought  up  in  its  revision  to  the  present  time.  In 
this  edition  we  have  also  included  the  beautiful  series 
of  plates  illustrative  of  the  text,  and  in  the  last  edi- 
tion published  separately.  There  are  twenty  of  these 
plates,  nearly  all  of  them  colored  to  nature,  and  ex- 
hibiting with  great  fidelity  the  various  groups  of 
diseases  treated  of  in  the  body  of  the  work. — Cin- 
cinnati Lancet , June,  1863. 

No  one  treating  skin  diseases  should  be  without 
a copy  of  this  standard  work.  — Canada  Lancet. 
August,  1S63. 


We  can  safely  recommend  it  to  the  profession  as 
the  best  work  on  the  subject  now  in  existence  in 
the  English  language. — Medical  Times  and  Gazette. 

Mr.  Wilson’s  volume  is  an  excellent  digest  of  the 
actual  amount. of  knowledge  of  cutaneous  diseases; 
it  includes  almost  every  fact  or  opinion  of  importance 
connected  with  the  anatomy  and  pathology  of  the 
skin. — British  and  Foreign  Medical  Review. 

These  plates  are  very  accurate,  and  are  executed 
with  an  elegance  and  taste  which  are  highly  creditable 
to  the  artistic  skill  of  the  American  artist  who  executed 
them. — St.  Louis  Med.  Journal. 

The  drawings  are  very  perfect,  and  the  finish  and 
coloring  artistic  and  correct ; the  volume  is  an  indis- 
pensable companion  to  the  book  it  illustrates  and 
completes. — Charleston  Medical  Journal. 


JOY  THE  SAME  AUTHOR.  

THE  STUDENT’S  BOOK  OF  CUTANEOUS  MEDICINE  and  Dis- 


eases of  the  skin.  In  one  very  handsome  royal  12mo.  volume.  $3  50.  (Now  Ready.) 


This  new  class-hook  will  be  admirably  adapted  to  I Thoroughly  practical  in  the  best  sense. — Brit.  Ned. 
the  necessities  of  students. — Lancet.  \ Journal. 


J^Y  THE  SAME  AUTHOR.  

HEALTHY  SKIN ; a Popular  Treatise  on  the  Skin  and  Hair,  their 

Preservation  and  Management.  One  vol.  12mo.,  pp.  291,  with  illustrations,  cloth.  $1  00 


jyELIGAN  (J.  MOOEE),  M.D.,  M.E.I.A., 

A PRACTICAL  TREATISE  ON  DISEASES  OF  THE  SKIN. 

Fifth  American,  from  the  second  and  enlarged  Dublin  edition  by  T.  W.  Belcher,  M.  D. 
In  one  neat  royal  12mo.  volume  of  462  pages,  extra  cloth.  $2  25.  ( Just  Issued.) 


Of  the  remainder  of  the  work  we  have  nothing  be- 
yond unqualified  commendation  to  offer.  It  is  so  far 
the  most  complete  one  of  its  size  that  has  appeared, 
and  for  the  student  there  can  be  none  which  can  com- 
pare with  it  in  practical  value.  All  the  late  disco- 
veries in  Dermatology  have  been  duly  noticed,  and 
their  value  justly  estimated ; in  a word,  the  work  is 
fully  up  to  the  times,  and  is  thoroughly  stocked  with 
most  valuable  information. — New  York  Med.  Record , 
Jan.  15,  1S67. 


This  instructive  little  volume  appears  once  more. 
Since  the  death  of  its  distinguished  author,  the  study 
of  skin  diseases  has  been  considerably  advanced,  and 
the  results  of  these  investigations  have  been  added 
by  the  present  editor  to  the  original  work  of  Dr.  Neli- 
gan.  This,  however,  has  not  so  far  increased  its  bulk 
as  to  destroy  its  reputation  as  the  most  convenient 
manual  of  diseases  of  the  skin  that  can  be  procured 
by  the  student. — Chicago  Med.  Journal , Dec.  1S66. 


JjY  THE  SAME  AUTHOR.  

ATLAS  OF  CUTANEOUS  DISEASES.  In  one  beautiful  quarto 


volume,  with  exquisitely  colored  plates, 
disease.  Extra  cloth,  $5  50. 

The  diagnosis  of  eruptive  disease,  however,  under 
all  circumstances,  is  very  difficult.  Nevertheless, 
Dr.  Neligan  has  certainly,  “as  far  as  possible,”  given 
a faithful  and  accurate  representation  of  this  class  of 
diseases,  and  there  can  be  no  doubt  that  these  plates 
will  be  of  great  use  to  the  student  and  practitioner  in 
drawing  a diagnosis  as  to  the  class,  order,  and  species 
to  which  the  particular  case  may  belong.  While 
looking  over  the  “Atlas”  we  have  been  induced  to 
examine  also  the  “Practical  Treatise,”  and  we  are 
inclined  to  consider  it  a very  superior  work,  com- 
bining accurate  verbal  description  with  sound  views 


&c.,  presenting  about  one  hundred  varieties  of 

of  the  pathology  and  treatment  of  eruptive  diseases. 
It  possesses  the  merit  of  giving  short  and  condensed 
descriptions,  avoiding  the  tedious  minuteness  of 
many  writers,  while  at  the  same  time  the  work,  as 
its  title  implies,  is  strictly  practical. — Glasgow  Med. 
Journal. 

A compend  which  will  very  much  aid  the  practi- 
tioner in  this  difficult  branch  of  diagnosis.  Taken 
with  the  beautiful  plates  of  the  Atlas,  which  are  re- 
markable for  their  accuracy  and  beauty  of  coloring, 
it  constitutes  a very  valuable  addition  to  the  library 
of  a practical  man. — Buffalo  Med.  Journal. 


TJILLIEE  [THOMAS],  M.D., 

-I  A-  Physician  to  the  Skin  Department  of  University  College  Hospital , &c. 

HAND-BOOK  OF  SKIN  DISEASES,  for  Students  and  Practitioners. 

[n  one  neat  royal  12mo.  volume  of  about  300  pages,  with  two  plates;  extra  cloth,  $2  25. 
(Just  Issued.) 


Henry  C.  Lea’s  Publications — ( Diseases  of  Children). 


QONDIE  [D.  FRANCIS),  M.  D. 

A PRACTICAL  TREATISE  ON  THE  DISEASES  OF  CHILDREN. 

Fifth  edition,  revised  and  augmented.  In  one  large  octavo  volume  of  over  750  closely- 
printed  pages,  extra  cloth.  $4  50. 


Dr.  Condie’s  scholarship,  acumen,  industry,  and 
practical  sense  are  manifested  in  this,  as  in  all  his 
numerous  contributions  to  science. — Dr.  Hotraes's 
Report  to  the  American  Medical  Association. 

Taken  as  a whole,  in  our  judgment,  Dr.  Condie’s 
treatise  is  the  one  from  the  perusal  of  which  the 
practitioner  in  this  country  will  rise  with  the  great- 
est satisfaction. — Western  Journal  of  Medicine  and 
Surgery. 

In  the  department  of  infantile  therapeutics,  the  work 
of  Dr.  Condie  is  considered  one  of  the  best  in  the  Eng- 
lish language. — The  Stethoscope. 

As  we  said  before,  we  do  not  know  of  a better  book 
on  Diseases  of  Children,  and  to  a large  part  of  its  re- 
commendations we  yield  an  unhesitating  concurrence. 
— Buffalo  Medical  Journal. 

The  work  of  Dr.  Condie  is  unquestionably  a very 
able  one.  It  is  practical  in  its  character,  as  its  title 
imports ; but  the  practical  precepts  recommended  in 


it  are  based,  as  all  practice  should  be,  upon  a familiar 
knowledge  of  disease.  The  opportunities  of  Dr.  Con- 
die for  the  practical  study  of  the  diseases  of  children 
have  been  great,  and  his  work  is  a proof  that  they  have 
not  been  thrown  away.  He  has  read  much,  but  ob- 
served more  ; and  we  think  that  we  may  safely  say 
that  the  American  student  cannot  find,  in  his  own 
language,  a better  book  upon  the  subject  of  which  it 
treats. — Am.  Journal  Medical  Sciences. 

We  pronounced  the  first  edition  to  be  the  best  work 
on  the  diseases  of  children  in  the  English  language, 
and,  notwithstanding  all  that  has  been  published,  we 
still  regard  it  in  that  light. — Medical  Examiner. 

The  value  of  works  by  native  authors  on  the  dis- 
eases which  the  physician  is  called  upon  to  combat 
will  be  appreciated  by  all,  and  the  work  of  Dr.  Con- 
die has  gained  for  itself  the  character  of  a safe  guide 
for  students,  and  a useful  work  for  consultation  by 
those  engaged  in  practice. — N.  Y.  Med.  Times. 


WEST  [CHARLES],  M.D., 

rhysician  to  the  Hospital  for  Sick  Children,  &c. 

LECTURES  ON  THE  DISEASES  OF  INFANCY  AND  CHILD- 

HOOD.  Fourth  American  from  the  fifth  revised  and  enlarged  English  edition.  In  one 
large  and  handsome  octavo  volume  of  656  closely-printed  pages.  Extra  cloth,  $4  50  ; 
leather,  $5  50*  {Just  issued.) 


This  work  may  now  fairly  claim  the  position  of  a standard  authority  and  medical  classic.  Five 
editions  in  England,  four  in  America,  four  in  Germany,  and  translations  in  French,  Danish, 
Dutch,  and  Russian,  show  how  fully  it  has  met  the  wants  of  the  profession  by  the  soundness  of  its 
views  and  the  clearness  with  which  they  are  presented.  Few  practitioners,  indeed,  have  had  the 
opportunities  of  observation  and  experience  enjoyed  by  the  Author.  In  his  Preface  he  remarks, 
“The  present  edition  embodies  the  results  of  1200  recorded  cases  and  of  nearly  400  post-mortem 
examinations,  collected  from  between  30,000  and  40,000  children,  who,  during  the  past  twenty- 
six  years,  have  come  under  my  care,  either  in  public  or  in  private  practice.”  The  universal  favor 
with  which  the  work  has  been  received  shows  that  the  author  has  made  good  use  of  these  unusual 


advantages. 

Of  all  the  English  writers  on  the  diseases  of  chil- 
dren, there  is  no  one  so  entirely  satisfactory  to  us  as 
Dr.  West.  For  years  we  have  held  his  opinion  as 
judicial,  and  have  regarded  him  as  one  of  the  highest 
living  authorities  in  the  difficult  department  of  medi- 
cal science  in  which  he  is  most  widely  known.  His 
writings  are  characterized  by  a sound,  practical  com- 
mon sense,  at  the  same  time  that  they  bear  the  marks 
of  the  most  laborious  study  and  investigation.  We 
commend  it  to  all  as  a most  reliable  adviser  on  many 
occasions  when  many  treatises  on  the  same  subjects 
will  utterly  fail  to  help  us.  It  is  supplied  with  a very 
copious  general  index,  and  a special  index  to  the  for- 
mulas scattered  throughout  the  work. — Boston  Med. 
and  Surg.  Journal , April  26,  1S66. 

Dr.  West’s  volume  is,  in  our  opinion,  incomparably 
the  best  authority  upon  the  maladies  of  children 
that  the  practitioner  can  consult.  Withal,  too — a 
minor  matter,  truly,  but  still  not  one  that  should  be 
neglected — Dr.  West’s  composition  possesses  a pecu- 
liar charm,  beauty  and  clearness  of  expression,  thus 
affording  the  reader  much  pleasure,  even  independent 
of  that  which  arises  from  the  acquisition  of  valuable 
truths. — Cincinnati  Jour,  of  Medicine , March,  1S66. 

We  have  long  regarded  it  as  the  most  scientific  and 
practical  book  on  diseases  of  children  which  has  yet 
appeared  in  this  country. — Buffalo  Medical  Journal. 

Dr.  West’s  book  is  the  best  that  has  ever  been 
written  in  the  English  language  on  the  diseases  of 


infancy  and  •hildhood. — Columbus  Review  of  Med. 
and  Surgery. 

To  occupy  in  medical  literature,  in  regard  to  dis- 
eases of  children  the  enviable  position  which  Dr. 
Watson’s  treatise  does  on  the  diseases  of  adults  is 
now  very  generally  assigned  to  our  author,  and  his 
book  is  in  the  hands  of  the  profession  everywhere  as 
an  original  work  of  great  value. — Md.  and  Va.  Med. 
and  Surg.  Journal. 

Dr.  West’s  works  need  no  recommendation  at  this 
date  from  any  hands.  The  volume  before  us,  espe- 
cially, has  won  for  itself  a large  and  well-deserved 
popularity  among  the  profession,  wherever  the  Eng- 
lish tongue  is  spoken.  Many  years  will  elapse  before 
it  will  be  replaced  in  public  estimation  by  any  similar 
treatise,  and  seldom  again  will  the  same  subject  be 
discussed  in  a clearer,  more  vigorous*,  or  pleasing 
style,  with  equal  simplicity  and  power. — Charleston 
Med.  Jour,  and  Review. 

There  is  no  part  of  the  volume,  no  subject  on  which 
it  treats  which  does  not  exhibit  the  keen  perception, 
the  clear  judgment,  and  the  sound  reasoning  of  the 
author.  It  will  be  found  a most  useful  guide  to  the 
young  practitioner,  directing  him  in  his  management 
of  children’s  diseases  in  the  clearest  possible  manner, 
and  enlightening  him  on  many  a dubious  pathological 
point,  while  the  older  one  will  find  in  it  many  a sug- 
gestion and  practical  hint  of  great  value. — Brit.  Am. 
Med.  Journal. 


T)EWEES  ( WILLIAM  P.),  M.D., 

■U  Late  Professor  of  Midwifery,  &c.,  in  the  University  of  Pennsylvania,  &c. 

A TREATISE  ON  THE  PHYSICAL  AND  MEDICAL  TREAT- 
MENT OF  CHILDREN.  Eleventh  edition,  with  the  author's  last  improvements  and  cor- 
rections. In  one  octavo  volume  of  54S  pages.  $2  SO. 


Henry  C.  Lea’s  Publications — ( Diseases  of  Women). 


23 


JlfEIGS  ( CHARLES  D.),  M.  D., 

Late  Professor  of  Obstetrics,  &c.  in  Jefferson  Medical  College,  Philadelphia. 


WOMAN:  HER  DISEASES  AND  THEIR  REMEDIES.  A Series 

of  Lectures  to' his  Class.  Fourth  and  Improved  edition.  In  one  large  and  beautifully 
printed  octavo  volume  of  over  700  pages,  extra  cloth,  $5  00  ; leather,  $6  00. 


That  this  work  has  been  thoroughly  appreciated 
by  the  profession  of  this  country  as  well  as  of  Europe, 
is  fully  attested  by  the  fact  of  its  having  reached  its 
fourth  edition  in  a period  of  less  than  twelve  years. 
Its  value  has  been  much  enhanced  by  many  impor- 
tant additions,  and  it  contains  a fund  of  useful  in- 
formation, conveyed  in  an  easy  and  delightful  style. 
Every  topic  discussed  by  the  author  is  rendered  so 
plain  as  to  be  readily  understood  by  every  student : 
and,  for  our  own  part,  we  consider  it  not  only  one  of 
the  most  readable  of  books,  but  one  of  priceless  value 
to  the  practitioner  engaged  in  the  practice  of  those 
diseases  peculiar  to  females. — N.Am.  Med.-Chir.  Re- 
view. 

We  read  the  book  and  find  him  more — an  original 
thinker,  an  eloquent  expounder,  and  a thorough 
practitioner.  The  book  is  but  twelve  years  old,  but 
it  has  been  so  much  appreciated  by  the  profession 
that  edition  after  edition  has  been  demanded,  and 
now  the  fourth  is  on  the  table  by  us.  We  recom- 


mend with  great  pleasure  a much  improved  edition 
of  a work  in  which  we  saw  little  room  for  •improve- 
ment.— Nashville  Medical  Journal. 

We  greet  this  new  edition  of  Dr.  Meigs’  work  on 
woman  with  much  pleasure,  and  commend  it  to  the 
profession,  especially  to  the  younger  members,  who 
may  receive  much  valuable  instruction  from  its 
pages,  conveyed  in  a pleasing  style.  The  teaching 
throughout  the  work  reflects  the  highest  credit  upon 
the  head  and  heart  of  the  author. — Chicago  Medical 
Journal. 

The  rules  of  the  art  here  described,  the  obstetrical 
opinions  here  expressed,  the  general  directions  and 
advice  given  and  suggested,  are,  beyond  any  cavil, 
unexceptionably  sa'gacious  and  prudent.  They  are 
founded  on  a large  practice,  have  been  tested  by  a 
long  experience,  and  come  from  lips  to  whose  teach- 
ing thousands  have  listened  for  many  years,  and 
never  without  profit. — Charleston  Med.  Journal  and 
Review. 


JfY  THE  SAME  AUTHOR.  

ON  THE  NATURE,  SIGNS,  AND  TREATMENT  OF  CHILDBED 

FEVER.  In  a Series  of  Letters  addressed  to  the  Students  of  his  Class.  In  one  handsome 
octavo  volume  of  365  pages,  extra  cloth.  $2  00. 


(JH  UR  CHILL  ( FLEETWOOD ),  M.  D.,  M.  R.  I.  A.  . 

ON  THE  DISEASES  OP  WOMEN;  including  those  of  Pregnancy 

and  Childbed.  A new  American  edition,  revised  by  the  Author.  With  Notes  and  Additions, 
by  D.  Francis  Condie,  M.  D.,  author  of  “ A Practical  Treatise  on  the  Diseases  of  Chil- 
dren.” With  numerous  illustrations.  In  one  large  and  handsome  octavo  volume  of  768 
pages,  extra  cloth,  $4  00 ,*  leather,  $5  00. 

From  the  Author' s Preface. 

In  reviewing  this  edition,  at  the  request  of  my  American  publishers,  I have  inserted  several 
new  sections  and  chapters,  and  I have  added,  I believe,  all  the  information  we  have  derived  from 
recent  researches ; in  addition  to  which  the  publishers  have  been  fortunate  enough  to  secure  the 
services  of  an  able  and  highly  esteemed  editor  in  Dr.  Condie. 


As  an  epitome  of  all  that  is  known  in  this  depart- 
ment of  medicine,  the  book  before  us  is  perhaps  the 
fullest  and  most  valuable  in  the  English  language. 
— Dublin  Medical  Press. 

It  was  left  for  Dr.  Churchill  to  gather  the  scat- 
tered facts  from  their  various  sources,  and  reduce 
them  to  a general  system.  This  he  has  done  with  a 
masterly  hand  in  the  volume  now  before  us ; in 
which,  to  the  results  o£  his  own  extensive  observa- 
tion, he  has  added  the  views  of  all  British  and  for- 
eign writers  of  any  note;  thus  giving  us  in  a com- 
plete form,  all  that  is  known  upon  this  subject  at  the 


present  day.  To  Dr.  Churchtll,  then,  are  the  pro- 
fession deeply  indebted  for  supplying  them  with  so 
great  a desideratum — the  achievement  of  which  de- 
servedly entitles  his  name,  already  intimately  asso- 
ciated with  the  diseases  of  women,  to  rank  very  high 
as  an  authority  upon  this  subject.  We  would  briefly 
characterize  it  as  one  of  the  most  useful  which  has 
issued  from  the  press  for  many  years.  To  all  it  bears 
its  own  recommendation  ; and  will  be  found  to  be 
invaluable  to  the  student  as  a text-book,  no  less  than 
as  a compendious  work  of  reference  to  the  qualified 
practitioner. — Glasgow  Med.  Journal. 


J^Y  THE  SAME  AUTHOR.  

ESSAYS  ON  THE  PUERPERAL  FEVER,  AND  OTHER  DIS- 
EASES PECULIAR  TO  WOMEN.  Selected  from  the  writings  of  British  Authors  previ- 
ous to  the  close  of  the  Eighteenth  Century.  In  one  neat  octavo  volume  of  about  450 
pages,  extra  cloth.  $2  50. 


rrHOMAS  (T.  GAILLARD),  M.D., 

A Professor  of  Obstetrics,  &c.  in  the  College  of  Physicians  and  Surgeons,  N.  ¥.,  & re. 


A COMPLETE  PRACTICAL  TREATISE  ON  THE  DISEASES  OF 

FEMALES.  In  one  large  and  handsome  octavo  volume,  with  illustrations.  ( Nearly  Ready.) 


J)ROWN  ( ISAAC  BAKER),  M.  D. 

ON  SOME  DISEASES  OF  WOMEN  ADMITTING  OF  SURGICAL 

TREATMENT.  With  handsome  illustrations.  One  volume  8vo.,  extra  cloth,  pp.  276. 


$1  60. 


ASHWELL’S  PRACTICAL  TREATISE  ON  THE  DIS- 
EASES PECULIAR  TO  WOMEN.  Illustrated  by 
Cases  derived  from  Hospital  and  Private  Practice. 
Third  American,  from  the  Third  and  revised  Lon- 
don edition.  In  one  octavo  volume,  extra  cloth, 
of  52S  pages.  $3  50. 

EIGBY  ON  THE  CONSTITUTIONAL  TREATMENT 
OF  FEMALE  DISEASES.  In  one  neat  royal  12mo. 
volume,  extra  cloth,  of  about  250  pages.  $1  00. 


DEWEES’S  TREATISE  ON  THE  DISEASES  OF  FE- 
MALES. With  illustrations.  Eleventh  Edition, 
with  the  Author’s  last  improvements  and  correc- 
tions. In  one  octavo  volume  of  536  pages,  with 
plates,  extra  cloth,  $3  00. 

COLOMBAT  DE  L’ISERE  ON  THE  DISEASES  OF 
FEMALES.  Translated  by  C.  D.  Meigs,  M.  D.  Se- 
cond edition.  In  one  vol.  Svo,  extra  cloth,  with 
numerous  wood-cuts.  pp.  720.  $3  75. 


24 


Henry  C.  Lea’s  Publications — ( Diseases  of  Women). 
JfODGE  {HUGH  L.),  31.  D. 

OX  DISEASES  PECULIAR  TO  WOMEX;  including  Displacements 

of  the  Uterus.  With  original  illustrations.  In  one  beautifully  printed  octavo  volume  of 
nearly  500  pages,  extra  cloth.  $3  75. 

Indeed,  although  no  part  of  the  volume  is  not  emi- 
nently deserving  of  perusal  and  study,  we  think  that 
the  nine  chapters  devoted  to  this  subject  are  espe- 
cially so,  and  we  know  of  no  more  valuable  mono- 
graph upon  the  symptoms,  prognosis,  and  manage- 
ment of  these  annoying  maladies  than  is  constituted 
by  this  part  of  the  work.  We  cannot  but  regard  it  as 
one  of  the  most  original  and  most  practical  works  of 

jyEST  [CHARLES),  31.d7~ 

LECTURES  OX  THE  DISEASES  OF  WOMEX.  Second  American, 

from  the  second  London  edition.  In  one  neat  octavo  volume  of  about  500  pages,  extra 
cloth.  $3  25. 

We  have  thus  embodied,  in  this  series  of  lectures, 
one  of  the  most  valuable  treatises  on  the  diseases  of 
the  female  sexual  system  unconnected  with  gestation, 
in  our  language,  and  one  which  cannot  fail,  from  the 
lucid  manner  in  which  the  various  subjects  have 
been  treated,  and  the  careful  discrimination  used -in 
dealing  only  with  facts,  to  recommend  the  volume  to 
the  careful  study  of  every  practitioner,  as  affording 
his  safest  guides  to  practice  within  our  knowledge. 

We  ha  ve  seldom  perused  a work  of  a more  thoroughly 
practical  character  than  the  one  before  us.  Every 
page  teems  with  the  most  truthful  and  accurate  infor- 
mation, and  we  certainly  do  not  know  of  any  other 
work  from  which  the  physician,  in  active  practice, 
can  more  readily  obtain  advice  of  the  soundest  cha- 
racter upon  the  peculiar  diseases  which  have  been 
made  the  subject  of  elucidation. — British  Am.  Med. 

Journal. 

We  return  the  author  our  grateful  thanks  for  the 
vast  amount  of  instruction  he  has  afforded  us.  His 
valuable  treatise  needs  no  eulogy  on- our  part.  His 
graphic  diction  and  truthful  pictures  of  disease  all 
speak  for  themselves. — Medico-Chirurg.  Review. 

Most  justly  esteemed  a standard  work It 

bears  evidence  of  having  been  carefully  revised,  and 
is  well  worthy  of  the  fame  it  has  already  obtained. 

—Dub.  Med.  Quar.  Jour. 

Br  THE  SAME  AUTHOR.  

AX  EXQUIRY  IXTO  THE  PATHOLOGICAL  IMPORTAXCE  OF 

ULCERATION  OF  THE  OS  UTERI.  In  one  neat  octavo  volume,  extra  cloth.  $1  25. 

£ 131  PS  ON  [ SIR  JA3IES  Y.),  31.  D. 

CLIXICAL  LECTURES  OX  THE  DISEASES  OF  WOMEX.  With 

numerous  illustrations.  In  one  handsome  octave  volume  of  over  500  pages,  extra  cloth.  $4. 

The  principal  topics  embraced  in  the  Lectures  are  Vesico-Vaginal  Fistula,  Cancer  of  the  Uterus, 
Treatment  of  Carcinoma  by  Caustics,  Dysmenorrhoea,  Amenorrhoea,  Closures,  Contractions,  Ac., 
of  the  Vagina,  Vulvitis,  Causes  of  Death  after  Surgical  Operations,  Surgical  Fever,  Phlegmasia 
Dolens,  Coccyodinia,  Pelvic  Cellulitis,  Pelvic  Hiematoma,  Spurious  Pregnancy,  Ovarian  Dropsy, 
Ovariotomy,  Cranioclasm,  Diseases  of  the  Fallopian  Tubes,  Puerperal  Mania,  Sub  Involution  and 
Super-Involution  of  the  Uterus,  Ac.  Ac. 


I As  a writer,  Dr.  West  stands,  in  our  opinion,  se- 
cond only  to  Watson,  the  “Macaulay  of  Medicine:’* 
lie  possesses  that  happy  faculty  of  clothing  instruc- 
tion in  easy  garments;  combining  pleasure  with 
profit,  he  leads  his  pupils,  in  spite  of  the  ancient  pro- 
verb, along  a royal  road  to  learning.  His  work  is  one 
which  will  not  satisfy  the  extreme  on  either  side,' but 
it  is  one  that  will  please  the  great  majority  who  are 
I seeking  truth,  and  one  that  will  convince  the  student 
j that  he  has  committed  himself  to  a candid,  safe,  and 
valuable  guide. — N.  A.  Med.-Chirurg  Review. 

1 We  must  now  conclude  this  hastily  written  sketch 
I with  the  confident  assurance  to  our  readers  that  the 
work  will  well  repay  perusal.  The  conscientious, 
painstaking,  practical  physician  is  apparent  on  every 
I page. — N.  Y.  Journal  of  Medicine. 

| We  have  to  say  of  it,  briefly  and  decidedly,  that  it 
is  the  best  work  on  the  subject  ih  any  language,  and 
that  it  stamps  Dr.  West  as  the  facile  prin ceps  of 
British  obstetric  authors. — Edinburgh  Med.  Journal. 

i We  gladly  recommend  his  lectures  as  in  the  highest 
1 degree  instructive  to  all  who  are  interested  in  ob- 
stetric practice. — London.  Lancet. 

We  know  of  no  treatise  of  the  kind  so  complete, 
and  vet  so  compact. — Chicaao  Med.  Journal 


| the  day — one  which  every  accoucheur  and  physician 
j should  most  carefully  read:  for  we  are  persuaded 
that  he  will  arise  from  its  perusal  with  new  ideas, 
i which  will  induct  him  into  a more  rational  practice 
in  regard  to  many  a suffering  female  who  may  have 
1 placed  her  health  in  his  hands. — British  American 
Journal , Feb.  1861. 


JAENNET  [HENRY),  31.  D. 

A PRACTICAL  TREATISE  OX  IXFLAMMATIOX  OF  THE 

UTERUS,  ITS  CERVIX  AND  APPENDAGES,  and  on  its  connection  with  Uterine  Dis- 
ease. Sixth  American,  from  the  fourth  and  revised  English  edition.  In  one  octavo  yolurne 
of  about  500  pages,  extra  cloth.  $3  75.  ( Recently  Issued.) 


From,  the  Author' s Preface. 

During  the  past  two  years,  this  revision  of  former  labors  has  been  my  principal  occupation,  and 
in  its  present  state  the  work  may  be  considered  to  embody  the  matured  experience  of  the  many 
years  I have  devoted  to  the  study  of  uterine  disease. 


Indeed,  the  entire  volume  is  so  replete  with  infor- 
mation, to  all  appearance  so  perfect  in  its  details,  that 
we  could  scarcely  have  thought  another  page  or  para- 
graph was  required  for  the  full  description  of  all  that 
Is  now  known  with  regard  to  the  diseases  under  con- 
sideration if  we  had  not  been  so  informed  by  the  au- 


thor. To  speak  of  it  except  in  terms  of  the  highest 
approval  would  be  impossible,  and  we  gladly  avail 
ourselves  of  the  present  opportunity  to  recommend 
it  in  the  most  unqualified  manner  to  the  profession. 
— Dublin  Med.  Press. 


Jf  Y THE  SAME  AUTHOR.  

A REVIEW  OF  THE  PRESEXT  STATE  OF  UTERIXE  PATHO- 

LOGY. In  one  small  octavo  volume,  extra  cloth.  50  cents. 


Henry  C.  Lea’s  Publications — ( Midioifery ). 


25 


TTODGE  {HUGH  L.),  M.  D., 

Late  Professor  of  Midwifery , &c.  in  the  University  of  Pennsylvania , &c. 

THE  PRINCIPLES  AND  PRACTICE  OF  OBSTETRICS.  Illus- 
trated with  large  lithographic  plates  containing  one  hundred  and  fifty-nine  figures  from 
original  photographs,  and  with  numerous  wood-cuts.  In  one  large  and  beautifully  printed 
quarto  volume  of  550  double-columned  pages,  strongly  bound  in  extra  cloth,  $14.  ( Late 

ly  published.) 

From  the  Author’s  Preface. 

“Influenced  by  these  motives,  the  author  has,  in  this  volume,  endeavored  to  present 
not  simply  his  own  opinions,  but  also  those  of  the  most  distinguished  authorities  in 
the  profession ; so  that  it  maybe  considered  a digest  of  the  theory  and  practice  of 
Obstetrics  at  the  present  period.” 

In  carrying  out  this  design,  the  ample  space  afforded  by  the  quarto  form  has  enabled  the  author 
to  enter  thoroughly  into  all  details,  and  in  combining  the  results  of  his  long  experience  and  study 
with  the  teachings  of  other  distinguished  authors,  he  cannot  fail  to  afford  to  the  practitioner  what- 
ever counsel  and  assistance  may  be  required  in  doubtful  cases  and  emergencies. 

A distinguishing  feature  of  the  work  is  the  profuseness  of  its  illustrations.  The  lithographic 
plates  are  all  original,  and,  to  insure  their  accuracy,  they  have  been  copied  from  photographs  taken 
expressly  for  the  purpose.  Besides  these,  a very  full  series  of  engravings  on  wood  will  be  found 
scattered  through  the  text,  so  that  all  the  details  given  by  the  author  are  amply  elucidated  by  the 
illustrations.  It  may  be  added  that  no  pains  or  expense  have  been  spared  to  render  the  mechanical 
execution  of  the  work  in  every  respect  worthy  of  the  character  and  value  of  the  teachings  it  contains. 

*%*  Specimens  of  the  plates  and  letterpress  will  be  forwarded  to  any  address  free  by  mail  on 
receipt  of  six  cents  in  postage  stamps. 

The  work  of  Dr.  Hodge  is  something  more  than  a 
simple  presentation  of  his  particular  views  in  the  de- 
partment of  Obstetrics ; it  is  something  more  than  an 
ordinary  treatise  on  midwifery ; it  is,  in  fact,  a cyclo- 
paedia of  midwifery.  He  has  aimed  to  embody  in  a 
single  volume  the  whole  science  and  art  of  Obstetrics. 

An  elaborate  text  is  combined  with  accurate  and  va- 
ried pictorial  illustrations,  so  that  no  fact  or  principle 
is  left  unstated  or  unexplained. — Am.  Med.  Times, 

Sept.  3, 1S64. 

We  should  like  to  analyze  the  remainder  of  this 
excellent  work,  but  already  has  this  review  extended 
beyond  our  limited  space.  We  cannot  conclude  this 
notice  without  referring  to  the  excellent  finish  of  the 
work.  In  typography  it  is  not  to  he  excelled;  the 
paper  is  superior  to  what  is  usually  afforded  by  our 
American  cousins,  quite  equal  to  the  best  of  English 
books.  The  engravings  and  lithographs  are  most 
beautifully  executed.  The  work  recommends  itself 
for  its  originality,  and  is  jn  every  way  a most  valu- 
able addition  to  those  on  the  subject  of  obstetrics. — 

, Canada  Med.  Journal,  Oct.  1S64. 

It  is  very  large,  profusely  and  elegantly  illustrated, 
and  is  fitted  to  take  its  place  near  the  works  of  great 
obstetricians.  Of  the  American  works  on  the  subject 
it  is  decidedly  the  best. — Edirib.  Med.  Jour.,  Dec.  ’64. 


MONTGOMERY  {W.  F.),  31.  D., 

*‘-U-  Professor  of  Midwifery  in  the  King's  and  Queen's  College  of  Physicians  in  Ireland. 

AN  EXPOSITION  OF  THE  SIGNS  AND  SYMPTOMS  OF  PREG- 

NANCY.  With  some  other  Papers  on  Subjects  connected  with  Midwifery.  From  the  second 
and  enlarged  English  edition.  With  two  exquisite  colored  plates,  and  numerous  wood-cuts. 
In  one  Very  handsome  octavo  volume  of  nearly  600  pages,  extra  cloth.  $3  75. 


We  have  examined  Professor  Hodge’s  work  with 
great  satisfaction ; every  topic  is  elaborated  most 
fully.  The  views  of  the  author  are  comprehensive, 
and  concisely  stated.  The  rules  of  practice  are  judi- 
cious, and  will  enable  the  practitioner  to  meet  every 
femergency  of  obstetric  complication  with  confidence. 
— Chicago  Med.  Journal , Aug.  1864. 

More  time  than  we  have  had  at  our  disposal  since 
we  received  the  great  work  of  Dr.  Hodge  is  necessary 
to  do  it  justice.  It  is  undoubtedly  by  far  the  most 
original,  complete,  and  carefully  composed  treatise 
on  the  principles  and  practice  of  Obstetrics  which  has 
ever  been  issued  from  the  American  press. — Pacific 
Med.  and  Surg.  Journal , July,  1S64. 

We  have  read  Dr.  Hodge’s  book  with  great  plea- 
sure, and  have  much  satisfaction  in  expressing  our 
commendation  of  it  as  a whole.  It  is  certainly  highly 
instructive,  and  in  the  main,  we  believe,  correct.  The 
great  attention  which  the  author  has  devoted  to  the 
mechanism  of  parturition,  taken  along  with  the  con- 
clusions at  which  he  has  arrived,  point,  we  think, 
conclusively  to  the  fact  that,  in  Britain  at  least,  the 
doctrines  of  Naegele  have  been  too  blindly  received. 
— Glasgow  Med.  Journal,  Oct.  1S64. 


11TILLER  [HENRY),  31.  D., 

Professor  of  Obstetrics  and  Diseases  of  Women  and  Children  in  the  University  of  Louisville. 

PRINCIPLES  AND  PRACTICE  OF  OBSTETRICS,  &c.;  including 

the  Treatment  of  Chronic  Inflammation  of  the  Cervix  and  Body  of  the  Uterus  considered 
as  a frequent  cause  of  Abortion.  With  about  one  hundred  illustrations  on  wood.  In  one 
very  handsome  octavo  volume  of  over  600  pages,  extra  cloth.  $3  75. 


RIGBY’S  SYSTEM  OF  MIDWIFERY.  With  Notes 
and  Additional  Illustrations.  Second  American 
edition.  One  volume  octavo,  extra  cloth,  422  pages. 
$2  50. 


DEWEES’S  COMPREHENSIVE  SYSTEM  OF  MID- 
WIFERY. Illustrated  by  occasional  cases  and 
many  engravings.  Twelfth  edition,  with  the  au- 
thor’s last  improvements  and  corrections.  In  one 
octavo  volume,  extra  cloth,  of  600  pages.  $3  50. 


26 


Henry  C.  Lea’s  Publications — ( Midwifery ). 


MEIQS  ( CHARLES  D.),  M.D., 

^ Lately  Professor  of  Obstetrics , A-c.,  f/te  Jefferson  Medical  College,  PhiladA'phia. 

OBSTETRICS:  THE  SCIENCE  AND  THE  ART.  Fifth  edition, 

revised.  With  one  Hundred  and  thirty  illustrations.  In  one  beautifully  printed  octavo 
volume  of  760  large  pages.  Extra  cloth,  $5  50,-  leather,  $6  50.  (No vj  ready.) 

From  the  Author’s  Preface. 

I tender  to  my  medical  brethren  a new  and  improved  edition  of  my  work  on  Midwifery,  for 
the  success  of  which  I am  so  greatly  indebted  to  them. 

As  this  is  probably  the  last  occasion  I shall  have  to  endeavor  to  make  the  book  better  for 
instruction  than  ever  it  was  before,  so  have  I felt  constrained  to  carefully  revise  every  one  of  its 
paragraphs,  that  I might  leave  it  in  a condition  more  worthy  to  be  offered  to  my  brethren. 


We  have,  therefore,  great  satisfaction  in  bringing 
under  our  readers’  notice  the  matured  views  of  the 
highest  American  authority  in  the  department  to 
which  he  has  devoted  his  life  and  talents.  They  com- 
prise not  only  the  “fruit  of  many  years  of  painful  toil 
in  the  acquisition  of  clinical  experience  and  know- 
ledge,” but  they  contain  also  the  evidences  of  an 
extended  acquaintance  with  European  medical  lite- 
rature, both  continental  and  British.  This  feature, 


together  with  the  elevation  of  tone  and  eloquence  in 
style  often  exhibited  by  the  author,  constitute  no 
slight  merit  in  works  on  the  subjects  with  which  the 
author  is  here  occupied. — London  Med.  Gazette. 

We  have  made  a somewhat  careful  examination  of 
this  new  edition  of  the  Science  and  the  Art  of  Obstet- 
rics, and  are  satisfied  that  there  is  no  better  or  more 
useful  guide  to  the  educated  practitioner. — New  Or- 
leans Monthly  Med.  Register. 


JIAMSB 0 TEAM  [FRANCIS  IT.),  M.  D. 

THE  PRINCIPLES  AND  PRACTICE  OF  OBSTETRIC  MEDI- 

CINE  AND  SURGERY,  in  reference  to  the  Process  of  Parturition.  A new  and  enlarged 
edition,  thoroughly  revised  by  the  author.  With  additions  by  W.  V.  Keating,  M.  D., 
Professor  of  Obstetrics,  &c.,  in  the  Jefferson  Medical  College,  Philadelphia.  In  one  large 
and  handsome  imperial  octavo  volume  of  650  pages,  strongly  bound  in  leather,  with  raised 
bands;  with  sixty-four  beautiful  plates,  and  numerous  wood-cuts  in  the  text,  containing  in 
all  nearly  200  large  and  beautiful  figures.  $7  00. 


We  will  only  add  that  the  student  will  learn  from 
it  all  he  need  to  know,  and  the  practitioner  will  find 
it,  as  a book  of  reference,  surpassed  by  none  other.— 
Stethoscope. 

The  character  and  merits  of  Dr.  Ramsbotham’s 
work  are  so  well  known  and  thoroughly  established, 
that  comment  is  unnecessary  and  praise  superfluous. 
The  illustrations,  which  are  numerous  and  accurate, 
are  executed  in  the  highest  style  of  art.  We  cannot 
too  highly  recommend  the  work  to  our  readers. — St. 
Louis  Med.  and  Surg.  Journal. 


To  the  physician’s  library  it  is  indispensable,  while 
to  the  student,  as  a text-book,  from  which  to  extract 
the  material  for  laying  the  foundation  of  an  education 
on  obstetrical  science,  it  has  no  superior. — Ohio  Med. 
and  Surg.  Journal. 

When  we  call  to  mind  the  toil  we  underwent  in 
acquiring  a knowledge  of  this  subject,  we  cannot  but 
envy  the  student  of  the  present  day  the  aid  which 
this  work  will  afford  him. — Am.  Jour,  of  the  Med. 
Sciences. 


(JIITJR CHILL  ( FLEETWOOD ),  M.D.,  M.R.I.A. 


ON  THE  THEORY  AND  PRACTICE  OF  MIDWIFERY.  A new 

American  from  the  fourth  revised  and  enlarged  London  edition.  With  notes  and  additions 
by  D.  Francis  Condie,  M.  D.,  author  of  a “Practical  Treatise  on  the  Diseases  of  Chil- 
dren,” Ac.  With  one  hundred  and  ninety-four  illustrations.  In  one  very  handsome  octavo 
volume  of  nearly  700  large  pages.  Extra  cloth,  $4  00;  leather,  $5  00. 

In  adapting  this  standard  favorite  to  the  wants  of  the  profession  in  the  United  States,  the  editor 
has  endeavored  to  insert  everything  that  his  experience  has  shown  him  would  be  desirable  for  the 
American  student,  including  a large  number  of  illustrations.  With  the  sanction  of  the  author, 
he  has  added,  in  the  form  of  an  appendix,  some  chapters  from  a little  “Manual  for  Midwives  and 
Nurses,”  recently  issued  by  Dr.  Churchill,  believing  that  the  details  there’ presented  can  hardly 
fail  to  prove  of  advantage  to  the  junior  practitioner.  The  result  of  all  these  additions  is  that  the 
work  now  contains  fully  one-half  more  matter  than  the  last  American  edition,  with  nearly  one- 
half  more  illustrations ; so  that,  notwithstanding  the  use  of  a smaller  type,  the  volume  contains 
almost  two  hundred  pages  more  than  before. 

No  effort  has  been  spared  to  secure  an  improvement  in  the  mechanical  execution  of  the  work 
equal  to  that  which  the  text  has  received,  and  the  volume  is  confidently  presented  as  one  of  the 
handsomest  that  has  thus  far  been  laid  before  the  American  profession  ; while  the  very  low  price 
at  which  it  is  offered  should  secure  for  it  a place  in  every  lecture-room  and  on  every  office  table. 


These  additions  render  the  work  still  more  com- 
plete and  acceptable  than  ever ; and  with  the  excel- 
lent style  in  which  the  publishers  have  presented 
this  edition  of  Churchill,  we  can  commend  it  to  the 
profession  with  great  cordiality  and  pleasure. — Cin- 
cinnati Lancet. 

Few  works  on  this  branch  of  medical  science  are 
equal  to  it,  certainly  none  excel  it,  whether  in  regard 
to  theory  or  practice,  and  in  one  respect  it  is  superior 
to  all  others,  viz.,  in  its  statistical  information,  and 
therefore,  on  these  grounds  a most  valuable  work  for 
the  physician,  student,  or  lecturer,  all  of  whom  will 
find  in  it  the  information  which  they  are  seeking. — 
Brit.  Am.  Journal. 

The  present  treatise  is  very  much  enlarged  and 
amplified  beyond  the  previous  editions  but  nothing 


has  been  added  which  could  be  well  dispensed  with. 
An  examination  of  the  table  of  contents  shows  how 
thoroughly  the  author  has  gone  over  the  ground,  and 
the  care  he  has  taken  in  the  text  to  present  the  sub- 
jects in  all  their  bearings,  will  render  this  new  edition 
even  more  necessary  to  the  obstetric  student  than 
were  either  of  the  former  editions  at  the  date  of  their 
appearance.  No  treatise  on  obstetrics  with  which  we 
are  acquainted  can  compare  favorably  with  this,  in 
respect  to  the  amount  of  material  which  has  been 
gathered  from  every  source. — Boston  Med.  atid  Surg. 
Journal. 

There  is  no  better  text-book  for  students,  or  work 
of  reference  and  study  for  the  practising  physician 
than  this.  It  should  adorn  and  enrich  every  medical 
library. — Chicago  Med.  Journal. 


Henry  C.  Lea’s  Publications — (Surgery), 


27 


QROSS  (SAMUEL  I).),  M.D., 

Professor  of  Surgery  in  the  Jefferson  Medical  College  of  Philadelphia. 


A SYSTEM  OF  SURGERY : Pathological,  Diagnostic,  Therapeutic, 

and  Operative.  Illustrated  by  upwards  of  Thirteen  Hundred  Engravings.  Fourth  edition, 
carefully  revised,  and  improved.  In  two  large  and  beautifully  printed  royal  octavo  volumes 
of  2200  pages,  strongly  bound  in  leather,  with  raised  bands.  $15  00. 

The  continued  favor,  shown  by  the  exhaustion  of  successive  large  editions  of  this  great  work, 
proves  that  it  has  successfully  supplied  a want  felt  by  American  practitioners  and  students.  Though 
but  littl^  over  six  years  have  elapsed  since  its  first  publication,  it  has  already  reached  its  fourth 
edition,  while  the  care  of  the  author  in  its  revision  and  correction  has  kept  it  in  a constantly  im- 
proved shape.  By  the  use  of  a close,  though  very  legible  type,  an  unusually  large  amount  of 
matter  is  condensed  in  its  pages,  the  two  volumes  containing  as  much  as  four  or  five  ordinary 
octavos.  This,  combined  with  the  most  careful  mechanical  execution,  and  its  very  durable  binding, 
renders  it  one  of  the  cheapest  works  accessible  to  the  profession.  Every  subject  properly  belonging 
to  the  domain  of  surgery  is  treated  in  detail,  so  that  the  student  who  possesses  this  work  may  be 
said  to  have  in  it  a surgical  library. 


It  must  long  remain  the  most  comprehensive  work 
on  this  important  part  of  medicine. — Boston  Medical 
and  Surgical  Journal , March  23,  1S65. 

We  have  compared  it  with  most  of  our  standard 
works,  such  as  those  of  Erichsen,  Miller,  Fergusson, 
Syme,  and  others,  and  we  must,  in  justice  to  our 
author,  award  it  the  pre-eminence.  As  a work,  com- 
plete in  almost  every  detail,  no  matter  how  minute 
or  trifling,  and  embracing  every  subject  known  in 
the  principles  and  practice  of  surgery,  we  believe  it 
stands  without  a rival.  Dr.  Gross,  in  his  preface,  re- 
marks “my  aim  has  been  to  embrace  the  whole  do- 
main of  surgery,  and  to  allot  to  every  subject  its 
legitimate  claim  to  notice;”  and,  we  assure  our 
readers,  he  has  kept  his  word.  It  is  a work  which 
we  can  most  confidently  recommend  to  our  brethren, 
for  its  utility  is  becoming  the  more  evident  the  longer 
it  is  upon  the  shelves  of  our  library. — Canada  Med. 
Journal , September,  1865. 

The  first  two  editions  of  Professor  Gross’  System  of 
Surgery  are  so  well  known  to  the  profession,  and  so 
highly  prized,  that  it  would  be  idle  for  us  to  speak  in 
praise  of  this  work.  — Chicago  Medical  Journal , 
September,  1865. 

We  gladly  indorse  the  favorable  recommendation 
of  the  work,  both  as  regards  matter  and  style,  which 
we  made  when  noticing  its  first  appearance. — British 
and  Foreign  Medico- Chirurgical  Review , Oct.  1865. 

# The  most  complete  work  that  has  yet  issued  from 
the  press  on  the  science  and  practice  of  surgery. — 
London  Lancet. 

This  system  of  surgery  is,  we  predict,  destined  to 
take  a commanding  position  in  our  surgical  litera- 
ture, and  be  the  crowning  glory  of  the  author’s  well 
earned  fame.  As  an  authority  on  general  surgical 
subjects,  this  work  is  long  to  occupy  a pre-eminent 
place,  not  only  at  home,  but  abroad.  We  have  no 
hesitation  in  pronouncing  it  without  a rival  in  our 
language,  and  equal  to  the  best  systems  of  surgery  in 
any  language. — N.  Y.  Med.  Journal. 

Not  only  by  far  the  best  text-book  on  the  subject, 
as  a whole,  within  the  reach  ^)f  American  students, 
but  one  which  will  be  much  more  than  ever  likely 
to  be  resorted  to  and  regarded  as  a high  authority 
abroad. — Am.  Journal  Med.  Sciences , Jan.  1865. 

The  work  contains  everything,  minor  and  major, 
operative  and  diagnostic,  including  mensuration  and 
examination,  venereal  diseases,  and  uterine  manipu- 
lations and  operations.  It  is  a complete  Thesaurus 
of  modern  surgery,  where  the  student  and  practi- 


tioner shall  not  seek  in  vain  for  what  they  desire.— 
San  Francisco  Med.  Press,  Jan.  1865. 

Open  it  where  we  may,  we  find  sound  practical  in- 
formation conveyed  in  plain  language.  This  book  is 
no  mere  provincial  or  even  national  system  of  sur- 
gery, but  a work  which,  while  very  largely  indebted 
to  the  past,  has  a strong  claim  on  the  gratitude  of  the 
future  of  surgical  science. — Edinburgh  Med.  Journal , 
Jan.  1865. 

A glance  at  the  work  is  sufficient  to  show  that  the 
author  and  publisher  have  spared  no  labor  in  making 
it  the  most  complete  “System  of  Surgery”  ever  pub- 
lished in  any  country. — St.  Louis  Med.  and  Surg. 
Journal , April,  1865. 

The  third  opportunity  is  now  offered  during  our 
editorial  life  to  review,  or  rather  to  indorse  and  re- 
commend this  great  American  work  on  Surgery. 
Upon  this  last  edition  a great  amount  of  labor  has 
been  expended,  though  to  all  others  except  the  author 
the  work  was  regarded  in  its  previous  editions  as  so 
full  and  complete  as  to  be  hardly  capable  of  improve- 
ment. Every  chapter  has  been  revised ; the  text  aug- 
mented by  nearly  two  hundred  pages,  and  a con 
siderable  number  of  wood-cuts  have  been  introduced. 
Many  portions  have  been  entirely  re-written,  and  the 
additions  made  to  the  text  are  principally  of  a prac- 
tical character.  This  comprehensive  treatise  upon 
surgery  has  undergone  revisions  and  enlargements, 
keeping  pace  with  the  progress  of  the  art  and  science 
of  surgery,  so  that  whoever  is  in  possession  of  this 
, work  may  consult  its  pages  upon  any  topic  embraced 
within  the  scope  of  its  department,  and  rest  satisfied 
that  its  teaching  is  fully  up  to  the  present  standard 
of  surgical  knowledge.  It  is  also  so  comprehensive 
that  it  may  truthfully  be  said  to  embrace  all  that  is 
actually  known,  that  is  really  of  any  value  in  the 
diagnosis  and  treatment  of  surgical  diseases  and  acci- 
dents. Wherever  illustration  will  add  clearness  to  the 
subject,  or  make  better  or  more  lasting  impression,  it 
is  not  wanting;  in  this  respect  the  work  is  eminently 
superior. — Buffalo  Med.  Journal,  Dec.  1S64. 

A system  of  surgery  which  we  think  unrivalled  in 
our  language,  and  which  will  indelibly  associate  his 
name  with  surgical  science.  And  what,  in  our  opin- 
ion, enhances  the  value  of  the  work  is  that,  while  the 
practising  surgeon  will  find  all  that  he  requires  in  it, 
it  is  at  the  same  time  one  of  the  most  valuable  trea- 
tises which  can  be  put  into  the  hands  of  the  student 
seeking  to  know  the  principles  and  practice  of  this 
branch  of  the  profession  which  he  designs  subse- 
quently to  follow. — The  Brit.  Am.  Journ.,  Montreal. 


J£Y  THE  SAME  AUTHOR. 


A PRACTICAL  TREATISE  OH  THE  DISEASES,  INJURIES, 

AND  MALFORMATIONS  OF  THE  URINARY  BLADDER,  THE  PROSTATE  GLAND, 
AND  THE  URETHRA.  Second  edition,  revised  and  much  enlarged,  with  one  hundred 
and  eighty-four  illustrations.  In  one  large  and  very  handsome  octavo  volume,  of  over  nine 
hundred  pages,  extra  cloth.  $4  00. 

Whoever  will  peruse  the  vast  amount  of  valuable  guage  which  can  make  any  just  pretensions  to  be  its 
practical  information  it  contains  will,  we  think,  agree  equal. — N.  Y.  Journal  of  Medicine. 
with  us,  that  there  is  no  work  in  the  English  lan- 


J^Y  THE  SAME  AUTHOR.  

A PRACTICAL  TREATISE  ON  FOREIGN  BODIES  IN  THE 

AIR-PASSAGES.  In  one  handsome  octavo  volume,  extra  cloth,  with  illustrations, 

pp.  468.  $2  75. 


28 


Henry  C.  Lea’s  Publications — (Surgery). 


J7RICHSEN  {JOHN), 

Professor  of  Surgery  in  University  College , London. 

THE  SCIENCE  AND  ART  OF  SURGERY;  being  a Treatise  on  Sur- 

gical  Injuries,  Diseases,  and  Operations.  New  and  improved  American,  from  the  Second 
enlarged  and  carefully  revised  London  edition.  Illustrated  with  over  four  hundred  wood 
engravings.  In  one  large  and  handsome  octavo  volume  of  1000  closely  printed  pages;  extra 
cloth,  $6;  leather,  raised  bands,  $7. 


We  are  bound  to  state,  and  we  do  so  without  wish-  ' 
ing  to  draw  invidious  comparisons,  that  the  work  of  ^ 
Mr.  Erichsen,  in  most  respects,  surpasses  any  that 
lias  preceded  it.  Mr.  Erichsen’s  is  a practical  work,  ! 
combining  a due  proportion  of  the  “Science  and  Art 
of  Surgery.”  Having  derived  no  little  instruction 
from  it,  in  many  important  branches  of  surgery,  we 
can  have  no  hesitation  in  recommending  it  as  a valu- 
able book  alike  to  the  practitioner  and  the  student. 
— Dublin  Quarterly. 

Gives  a very  admirable  practical  view  of  the  sci- 
ence and  art  of  surgery  .-^Edinburgh  Med.  and  Surg. 
Journal. 

We  recommend  it  as  the  best  compendium  of  sur- 
gery in  our  language. — London  Lancet. 

It  is,  we  think,  the  most  valuable  practical  work 
on  surgery  in  existence,  both  for  young  and  old  prac- 
titioners.— Nashville  Med.  and  Surg.  Journal . 

The*limited  time  we  have  to  review  this  improved 
edition  of  a work,  the  first  issue  of  which  we  prized 


as  one  of  the  very  best,  if  not  the  best  text-book  of 
surgery  with  which  we  were  acquainted,  permits  us 
to  give  it  but  a passing  notice  totally  unworthy  of  its 
merits.  It  may  be  confidently  asserted,  that  no  work 
on  the  science  and  art  of  surgery  has  ever  received 
more  universal  commendation  or  occupied  a higher 
position  as  a general  text-book  on  surgery,  than  this 
trea  tise  of  Professor  Erichsen. — Savannah  Journal  of 
Medicine. 

In  fulness  of  practical  detail  and  perspicuity  of 
style,  convenience  of  arrangement  and  soundness  of 
discrimination,  as  well  as  fairness  and  completeness 
of  discussion,  it  is  better  suited  to  the  wants  of  both 
student  and  practitioner  than  any  of  its  predecessors. 
— Am.  Journal  of  Med.  Sciences. 

After  careful  and  frequent  perusals  of  Erichsen’s 
surgery,  we  are  at  a loss  fully  to  express  our  admira- 
tiou  of  it.  The  author’s  style  is  emiuentlv  didactic, 
and  characterized  by  a most  admirable  directness, 
clearness,  and  compactness. — Ohio  Med.  and  Surg. 
Journal. 


JjY  THE  SAME  AUTHOR.  [Ready  in  June.) 

ON  RAILWAY,  AND  OTHER  INJURIES  OF  THE  NERVOUS 

SYSTEM.  In  small  octavo  volume.  Extra  cloth,  $1  00. 


We  welcome  this  as  perhaps  the  most  practically 
useful  treatise  written  for  many  a day. — Medical 
Times. 

It  will  serve  as  a most  useful  aud  trustworthy  guide 


to  the  profession  in  general,  many  of  whom  may  be 
consulted  in  such  cases;  and  it  will,  no  doubt,  take 
its  place  as  a text-book  on  the  subject  of  which  it 
treats. — Medical  Press. 


JITILLER  {JAMES), 

-LrJ-  Late  Professor  of  Surgery  in  the  University  of  Edinburgh,  &c. 

PRINCIPLES  OF  SURGERY.  Fourth  American,  from  the  third  aud 

revised  Edinburgh  edition.  In  one  large  and  very  beautiful  volume  of  700  pages,  with 
two  hundred  and  forty  illustrations  on  wood,  extra  cloth.  $3  75. 

J^Y  THE  SAME  AUTHOR.  

THE  PRACTICE  OF.  SURGERY.  Fourth  American,  from  the  last 

Edinburgh  edition.  Revised  by  the  American  editor.  Illustrated  by  three  hundred  and 
sixty-four  engravings  on  wood.  In  one  large  octavo  volume  of  nearly  700  pages,  extra 
cloth.  $3  75. 


piRRIE  { WILLIAM),  F.  R.  S.  E., 

Professor  of  Surgery  in  the  University  of  Aberdeen. 

THE  PRINCIPLES  AND  PRACTICE  OF  SURGERY.  Edited  by 

John  Neill,  M.  D.,  Professor  of  Surgery  in  the  Penna.  Medical  College,  Surgeon  to  the 
Pennsylvania  Hospital,  &c.  In  one  very  handsome  octavo  volume  of  780  pages,  with  316 
illustrations,  extra  cloth.  $3  75. 


1 'YALES  {PHILIP  S.),  M.D.,  U.  s.  N. 

ELEMENTARY  OPERATIONS  OF  SURGERY,  INCLUDING  MINOR 

SURGERY,  ORTHOPRAXY,  AND  MECHANICAL  THERAPEUTICS.  In  one  large 
octavo  volume,  with  several  hundred  illustrations.  ( Nearly  Ready.) 


R GENT  (F.  ID.),  M.D. 

ON  BANDAGING  AND  OTHER  OPERATIONS  OF  MINOR  SUR- 

GERY.  New  edition,  with  an  additional  chapter  on  Military  Surgery.  One  handsome  royal 
12mo.  volume,  of  nearly  400  pages,  with  184  wood-cuts.  Extra  cloth,  $1  75. 


MALGAIGNJTS  OPERATIVE  SURGERY.  With  nu- 
merous illustrations  on  wood.  In  one  handsome 
octavo  volume,  extra  cloth,  of  nearly  600  pp.  $2  50. 

SKEWS  OPERATIVE  SURGERY.  In  one  very  hand- 
some octavo  volume,  extra  cloth,  of  over  650  pages, 
with  about  100  wood-cuts.  $3  25. 


FERGUSSOJTS  SYSTEM  OF  PRACTICAL  SURGERY. 
Fourth  American,  from  the  third  and  enlarged  Lon- 
don edition.  In  one  large  and  beautifully  printed 
. octavo  volume  of  about  700  pages,  with  393  hand- 
some illustrations.  Leather,  $4. 


29 


Henky  C.  Lea’s  Publications — {Surgery). 


J^RUITT  [ROBERT],  M.R.C.S.,  frc. 


THE  PRINCIPLES  AND  PRACTICE  OP  MODERN  STJRGERY. 

A new  and  revised  American,  from  the  eighth  enlarged  and  improved  London  edition.  Illus- 
trated with  four  hundred  and  thirty -two  wood-engravings.  In  one  very  handsome  octavo 
volume,  of  nearly  TOQlarge  and  closely  printed  pages.  Extra  cloth,  $4  00  ; leather,  $5  00. 


All  that  the  surgical  student  or  practitioner  could 
desire. — Dublin  Quarterly  Journal. 

It  is  a most  admirable  book.  We  do  not  know 
when  we  have  examined  one  with  more  pleasure. — 
Boston  Med.  and  Surg.  Journal. 

In  Mr.  Druitt’s  book,  though  containing  only  some 
seven  hundred  pages,  both  the  principles  and  the 
practice  of  surgery  are  treated,  and  so  clearly  and 
perspicuously,  as  to  elucidate  every  important  topic. 
The  fact  that  twelve  editions  have  already  been  called 
for,  in  these  days  of  active  competition,  would  of 
itself  show  it  to  possess  marked  superiority.  We 
have  examined  the  book  most  thoroughly,  and  can 
say  that  this  success  is  well  merited.  His  book, 
moreover,  possesses  the  inestimable  advantages  of 
having  the  subjects  perfectly  well  arranged  and  clas- 
sified, and  of  being  written  in  a style  at  once  clear 
and  succinct. — Am.  Journal  of  Med.  Sciences. 

Whether  we  view  Druitt’s  Surgery  as  a guide  to 
operative  procedures,  or  as  representing  the  latest 


theoretical  surgical  opinions,  no  work  that  we  are  at 
present  acquainted  with  can  at  all  compare  with  it. 
It  is  a compendium  of  surgical  theory  (if  we  may  use 
the  word)  and  practice  in  itself,  and  well  deserves 
the  estimate  placed  upon  it. — Brit.  Am.  Journal. 

Thus  enlarged  and  improved,  it  will  continue  to 
rank  among  our  best  text-books  on  elementary  sur- 
gery.— Columbus  Rev.  of  Med.  and  Surg. 

We  must  close  this  brief  notice  of  an  admirable 
work  by  recommending  it  to  the  earnest  attention  of 
every  medical  student. — Charleston  Medical  Journal 
and  Review. 

A text-book  which  the  general  voice  of  the  profes- 
sion in  both  England  and  America  has  commended  as 
one  of  the  most  admirable  “manuals,”  or,  “ vade 
mecum,”  as  its  English  title  runs,  which  can  be 
placed  in  the  hands  of  the  student.  The  merits  of 
Druitt’s  Surgery  are  too  well  known  to  every  one  to 
need  any  further  eulogium  from  us. — Nashville  Med, 
Journal. 


JJAMIL TON  (FRANK  K),  3RD., 

Professor  of  Fractures  and  Dislocations,  &c.  in  Bdlevue  Hosp.  Med.  College,  New  Tori. 


A PRACTICAL  TREATISE  ON  FRACTURES  AND  DISLOCA- 

TIONS.  Third  edition,  thoroughly  revised.  In  one  large  and  handsome  octavo  volume 
of  777  pages,  with  294  illustrations,  extra  cloth,  $5  75.  ( Just  Issued.) 

The  demand  which  has  so  speedily  exhausted  two  large  editions  of  this  work  shows  that  the 
author  has  succeeded  in  supplying  a want,  felt  by  the  profession  at  large,  of  an  exhaustive  treatise 
on  a frequent  and  troublesome  class  of  accidents.  The  unanimous  voice  of  the  profession,  abroad 
as  well  as  at  home,  has  pronounced  it  the  most  complete  work  to  which  the  surgeon  can  refer  for 
information  respecting  all  details  of  the  subject.  In  the  preparation  of  this  new  edition,  the 
author  has  sedulously  endeavored  to  render  it  worthy  a continuance  of  the  favor  which  has  been 
accorded  to  it,  and  the  experience  of  the  recent  war  has  afforded  a large  amount  of  material  which 
he  has  sought  to  turn  to  the  best  practical  account. 


In  fulness  of  detail,  simplicity  of  arrangement,  and 
accuracy  of  description,  this  work  stands  unrivalled. 
So  far  as  we  know,  no  other  work  on  the  subject  in 
the  English  language  can  be  compared  with  it.  While 
congratulating  our  trans-Atlantic  brethren  on  the 
European  reputation  which  Dr.  Hamilton,  along  with 
many  other  American  surgeons,  has  attained,  we  also 
may  be  proud  that,  in  the  mother  tongue,  a classical 
work  has  been  produced  which  need  not  tear  compa- 
rison with  the  standard  treatises  of  any  other  nation. 
— Edinburgh  Med.  Journal , Dec.  1866. 

The  credit  of  giving  to  the  profession  the  only  com- 
plete practical  treatise  on  fractures  and  dislocations 
in  our  language  during  the  present  century,  belongs 
to  the  author  of  the  work  before  us,  a distinguished 


American  professor  of  surgery;  and  his  book  adds 
one  more  to  the  list  of  excellent  practical  works  which 
have  emanated  from  his  country,  notices  of  which 
have  appeared  from  time  to  time  in  our  columns  du- 
ring the  last  few  months.— London  Lancet,  Dec.  15. 
1866. 

These  additions  make  the  work  much  more  valua- 
ble, and  it  must  be  accepted  as  the  most  complete 
monograph  on  the  subject,  certainly  in  our  own,  if 
not  even  in  any  other  language.— American  Journal 
Med.  Sciences , Jan.  1S67. 

This  is  the  most  complete  treatise  on  the  subject  in 
the  English  language.— Ranking's  Abstract,  Jan.  1S67. 

A mirror  of  all  that  is  valuable  in  modern  surgery. 
Richmond  Med.  Journal,  Nov.  1866. 


fj  UR  LING  ( T.B. ),  F.R.S., 

v"/  Surgeon  to  the  London  Hospital,  President  of  the  Hunterian  Society,  &c. 

A PRACTICAL  TREATISE  ON  DISEASES  OF  THE  TESTIS, 

SPERMATIC  CORD,  AND  SCROTUM.  Second  American,  from  the  second  and  enlarged 
English  edition.  In  one  handsome  octavo  volume,  extra  cloth,  with  numerous  illustra- 
tions. pp.  420.  $2  00. 


f>ARWELL  (RICHARD),  F.R.C.S., 

Assistant  Surgeon  Charing  Cross  Hospital,  &c. 

A TREATISE  ON  DISEASES  OF  THE  JOINTS.  Illustrated  with 

engravings  on  wood.  In  one  very  handsome  octavo  volume  of  about  500  pages ; extra  cloth, 
S3. 


BRODIE'S  CLINICAL  LECTURES  ON  SURGERY. 
1 vol.  Svo.,  330  pp.;  cloth,  $1  25. 

COOPER  ON  THE  STRUCTURE  AND  DISEASES  OF 
the  Testis,  and  on  the  Thymus  Gland.  One  vol. 
imperial  Svo.,  extra  cloth,  with  177  figures  on  29 
plates.  $2  50. 


COOPER’S  LECTURES  ON  THE  PRINCIPLES  AND 
Practice  of  Surgery.  In  one  very  large  octavo 
volume,  extra  cloth,  of  750  pages.  $2  00. 

GIBSON’S  INSTITUTES  AND  PRACTICE  OF  SUR- 
GERY. Eighth  edition,  improved  and  altered.  With 
thirty-four  plates.  In  two  handsome  octavo  vol- 
umes, about  1000  pages,  leather,  raised  hands.  $6  50. 


30 


Henry  C.  Lea’s  Publications — (Surgery). 


rrOYNBEE  [JOSEPH],  F.R.S., 

•*-  Aural  Surgeon  to  and  Lecturer  on  Surgery  at  St.  Mary's  Hospital. 


THE  DISEASES  OE  THE  EAR 

ment.  With  one  hundred  engravings  on 
handsomely  printed  octavo  volume  of  440 
The  appearance  of  a volume  of  Mr.  Toynbee’s,  there- 
fore, in  which  the  subject  of  aural  disease  is  treated 
in  the  most  scientific  manner,  and  our  knowledge  in 
respect  to  it  placed  fully  on  a par  with  that  which 
we  possess  respecting  most  other  organs  of  the  body, 
is  a matter  for  sincere  congratulation.  We  may  rea- 
sonably hope  that  henceforth  the  subject  of  this  trea- 
tise will  cease  to  be  among  the  opprobria  of  medical 
science. — London  Medical  Review. 


: their  Nature,  Diagnosis,  and  Treat- 

wood.  Second  American  edition.  In  one  very 
pages ; extra  cloth,  $4. 

The  work,  as  was  stated  at  the  outset  of  our  notice, 
is  a model  of  its  kind,  and  every  page  and  paragraph 
of  it  are  worthy  of  the  most  thorough  study.  Con- 
sidered all  in  all — as  an  original  work,  well  written, 
philosophically  elaborated,  and  happily  illustrated 
with  cases  and  drawings — it  is  by  far  the  ablest  mo- 
nograph that  has  ever  appeared  on  the  anatomy  and 
diseases  of  the  ear,  and  one  of  the  most  valuable  con- 
tributions to  the  art  and  science  of  surgery  in  the 
nineteenth  century. — N.  Am.  Med.-CUiirv.rg.  Review. 


T A TJRENCE  [JOHN  Z.),  F.  R.  C.  S.,  and  liTOON  [ ROBERT  C.). 

Editor  of  the  Ophthalmic  Review,  &c.  House  Surgeon  to  the  Southwark  Oph- 

thalmic  Hospital , &c. 

A HANDY-BOOK  OF  OPHTHALMIC  SURGERY,  for  the  use  of 

Practitioners.  With  numerous  illustrations, 
cloth.  $2  50.  (Just  Issued.) 


No  book  on  ophthalmic  surgery  was  more  needed. 
Designed,  as  it  is,  for  the  wants  of  the  busy  practi- 
tioner, it  is  the  neplus  ultra,  of  perfection.  It  epito- 
mizes all  the  diseases  incidental  to  the  eye  in  a clear 
and  masterly  manner,  not  only  enabling  the  practi- 
tioner readily  to  diagnose  each  variety  of  disease,  but 
affording  him  the  more  important  assistance  of  proper 
treatment.  Altogether  this  is  a work  which  ought 
certainly  to  be  in  the  hands  of  every  general  practi- 
tioner.— Dublin  Med.  Press  and  Circular , Sept.  12,  ’66. 

We  cordially  recommend  this  book  to  the  notice  of 
our  readers,  as  containing  an  excellent  outline  of 
modern  ophthalmic  surgery. — British  Med.  Journal , 
October  13,  1866. 


In  one  very  handsome  octavo  volume,  extra 

Not  only,  as  its  modest  title  suggests,  a “Handy- 
Book”  of  Ophthalmic  Surgery,  but  an  excellent  and 
well-digested  rtsumi  of  all  that  is  of  practical  value 
in  the  specialty. — New  York  Medical  Journal,  No- 
vember, 1866. 

This  object  the  authors  have  accomplished  in  a 
highly  satisfactory  manner,  and  we  know  no  work 
we  can  more  highly  recommend  to  the  “busy  practi- 
tioner” who  wishes  to  make  hirnself  acquainted  with 
the  recent  improvements  in  ophthalmic  science.  Such 
a work  as  this  was  much  wanted  at  this  time,  and 
this  want  Messrs.  Laurence  and  Moon  have  now  well 
supplied. — Am.  Journal  Med.  Sciences , Jan.  1867. 


TAW90N  (GEORGE),  F.  R.  C.  S.,  Engl. 

-U  Assistant  Surgeon  to  the  Royal  London  Ophthalmic  Hospital,  Moor  fields,  &c. 

INJURIES  OF  THE  EYE,  ORBIT,  AND  EYELIDS : their  Imme- 

diate  and  Remote  Effects.  With  about  one  hundred  illustrations.  In  one  very  hand- 
some octavo  volume,  extra  cloth,  $3  50.  (Just  Ready.) 

It  is  an  admirable  practical  book  in  the  highest  and  fulness  of  practical  knowledge.  We  predict  for  Mr. 
best  sense  of  the  phrase.  Copiously  illustrated  by  Lawson’s  work  a great  and  well-merited  success, 
excellent  woodcuts,  and  with  well-selected,  well-  We  are  confident  that  the  profession,  and  especially, 
described  cases,  it  is  written  in  plain,  simple  lan-  as  we  have  said,  our  country  brethren,  will  feel 
guage,  and  in  a style  the  transparent  clearness  and  grateful  to  him  for  having  given  them  in  it  a guide 
frankness,  so  to  speak,  of  which,  add  greatly  to  its  and  counsellor  fully  up  to  the  most  advanced  state  of 
value  and  usefulness.  Only  a master  of  his  subject  Ophthalmic  Surgery,  and  of  whom  they  can  make  a 
could  so  write;  every  topic  is  handled  with  an  ease,  trusty  and  familiar  friend. — London  Medical  Times 
decision,  and  straightforwardness,  that  show  the  and  Gazette,  May  IS,  1S67. 
skilful  and  highly  educated  surgeon  writing  from  I 


TONES  ( T . WHARTON),  F.R.S., 

a Professor  of  Ophthalmic  Med.  and  Surg.  in  University  College,  London. 

THE  PRINCIPLES  AND  PRACTICE  OF  OPHTHALMIC  MEDI- 
CINE AND  SURGERY.  With  one  hundred  and  seventeen  illustrations.  Third  and  re- 
vised American,  with  Additions  from  the  second  London  edition.  In  one  handsome  octavo 
volume  of  455  pages,  extra  cloth.  $3  25. 


JIT. A CKENZIE  (IF.),  31.  D., 

i'i  Surgeon  Oculist  in  Scotland  in  ordinary  to  her  Majesty,  &c. 

A PRACTICAL  TREATISE  ON  DISEASES  AND  INJURIES  OF 

THE  EYE.  To  which  is  prefixed  an  Anatomical  Introduction  explanatory  of  a Horizontal 
Section  of  the  Human  Eyeball,  by  Thomas  Whakton  Jones,  F.  R.  S.  From  the  fourth 
revised  and  enlarged  London  edition.  With  Notes  and  Additions  by  Addinell  Hewson, 
M.  D.,  Surgeon  to  Wills  Hospital,  Ac.  Ac.  In  one  very  large  and  handsome  octavo  volume 
of  1027  pages,  extra  cloth,  with  plates  and  numerous  wood-cuts.  §6  50. 


J JORLAND  (IF.  IF.),  31.  D. 

DISEASES  OF  THE  URINARY  ORGANS;  a Compendium  of  their 

Diagnosis,  Pathology,  and  Treatment.  With  illustrations.  In  one  large  and  handsome 
octavo  volume  of  about  600  pages,  extra  cloth.  $3  50. 

Taken  as  a whole,  we  can  recommend  Dr.  Norland's  I of  every  medical  or  surgical  practitioner. — Brit,  and 
compendium  as  a very  desirable  addition  to  the  library  | Ibr.  Med.-Chir.  Review,  April,  1So9. 


Henry  C.  Lea’s  Publications — ( Medical  Jurisprudence , &c.).  31 


rTAYLOR  ( ALFRED  S.),  M.D., 

J-  Lecturer  on  Med.  Jurisp.  and  Chemistry  in  Guy's  Hospital. 

MEDICAL  JURISPRUDENCE.  Sixth  American,  from  the  eighth 

and  revised  London  edition.  With  Notes  and  References  to  American  Decisions,  by  Cle- 
ment B.  Penrose,  of  the  Philadelphia  Bar.  In  one  large  octavo  volume  of  776  pages, 
extra  cloth,  $4  50  ; leather,  $5  50.  ( Now  Ready.) 

Considerable  additions  have  been  made  by  the  editor  to  this  edition,  comprising  some  important 
sections  from  the  author’s  larger  work,  “ The  Principles  and  Practice  of  Medical  Jurisprudence,’’ 
as  well  as  references  to  American  law  and  practice.  The  notes  of  the  former  editor,  Dr.  Harts- 
horne,  have  likewise  been  retained,  and  the  whole  is  presented  as  fully  worthy  to  maintain  the 
distinguished  position  which  the  work  has  acquired  as  a leading  text-book  and  authority  on  the 
subject 


A new  edition  of  a work  acknowledged  as  a stand- 
ard authority  everywhere  within  the  range  of  the 
English  language.  Considering  the  new  matter  intro- 
duced, on  trichiniasis  and  other  subjects,  and  the 
plates  representing  the  crystals  of  poisons,  etc. , it  may 
i fairly  be  regarded  as  the  most  compact,  comprehen- 
sive, and  practical  work  on  medical  jurisprudence 
which  has  issued  from  the  press,  and  the  one  best 
fitted  for  students. — Pacific  Med.  and  Surg.  Journal , 
Eeb.  1857. 

The  sixth  edition  of  this  popular  work  comes  to  us 
in  charge  of  a new  editor,  Mr.  Penrose,  of  the  Phila- 
delphia bar,  who  has  done  much  to  render  it  useful, 
not  only  to  the  medical  practitioners  of  this  country, 
but  to  those  of  his  own  profession.  Wisely  retaining 
the  references  of  the  former  American  editor,  Dr. 
Hartshorne,  he  has  added  many  valuable  notes  of  his 
own.  The  reputation  of  Dr.  Taylor’s  work  is  so  well 
established,  that  it  needs  no  recommendation.  He  is 
now  the  highest  living  authority  on  all  matters  con- 
nected with  forensic  medicine,  and  every  successive 
edition  of  his  valuable  work  gives  fresh  assurance  to 
his  many  admirers  that  he  will  continue  to  maintain 
his  well-earned  position.  No  one  should,  in  fact,  be 
without  a text-book  on  the  subject,  as  he  does  not 
know  but  that  his  next  case  may  create  for  him  an 
emergency  for  its  use.  To  those  who  are  not  the  for- 
tunate possessors  of  a reliable,  readable,  interesting, 
and  thoroughly  practical  work  upon  the  subject,  we 
would  earnestly  recommend  this,  as  forming  the  best 
groundwork  for  all  their  future  studies  of  the  more 


elaborate  treatises. — New  York  Medical  Record , Feb. 
15,  1867. 

The  present  edition  of  this  valuable  manual  is  a 
great  improvement  on  those  which  have  preceded  it. 
Some  admirable  instruction  on  the  subject  of  evidence 
and  the  duties  and  responsibilities  of  medical  wit- 
nesses has  been  added  by  the  distinguished  author, 
and  some  fifty  cuts,  illustrating  chiefly  the  crystalline 
forms  and  microscopic  structure  of  substances  used 
as  poisons,  inserted.  The  American  editor  has  also 
introduced  several  chapters  from  Dr.  Taylor’s  larger 
work,  ‘“The  Principles  and  Practice  of  Medical  Juris- 
prudence,” relating  to  trichiniasis,  sexual  malforma- 
tion, insanity  as  affecting  civil  responsibility,  suicidal 
mania,  and  life  insurance,  &c.,  which  add  considerably 
to  its  value.  Besides  this,  he  has  introduced  nume- 
rous references  to  cases  which  have  occurred  in  this 
country.  It  makes  thus  by  far  the  best  guide-book 
in  this  department  of  medicine  for  students  and  the 
general  practitioner  in  our  language. — Boston  Med . 
and  Surg.  Journal , Dec.  27,  1866. 

Taylor’s  Medical  Jurisprudence  has  been  the  text- 
book in  our  colleges  for  years,  and  the  present  edi- 
tion, with  the  valuable  additions  made  by  the  Ameri- 
can editor,  render  it  the  most  standard  work  of  the 
day,  on  the  peculiar  province  of  medicine  on  which 
it  treats.  The  American  editor,  Dr.  Hartshorne,  has 
done  his  duty  to  the  text,  and,  upon  the  whole,  we 
cannot  but  consider  this  volume  the  best  and  richest 
treatise  on  medical  jurisprudence  in  our  language.— 
Brit.  Am.  Med.  Journal. 


yyiNSLOW  {FORBES),  M.D.,  D.C.L.,  frc. 

ON  OBSCURE  DISEASES  OF  THE  BRAIN  AND  DISORDERS 

OF  THE  MIND;  their  incipient  Symptoms,  Pathology,  Diagnosis,  Treatment,  and  Pro- 
phylaxis. Second  American,  from  the  third  and  revised  English  edition.  In  one  handsome 
octavo  volume  of  nearly  600  pages,  extra  cloth.  $4  25.  ( Just  Issued.) 


Of  the  merits  of  Dr.  Winslow’s  treatise  the  profes- 
sion has  sufficiently  judged.  It  has  taken  its  place  in 
the  front  rank  of  the  works  upon  the  special  depart- 
ment of  practical  medicine  to  which  it  pertains. — 
Cincinnati  Journal  of  Medicine , March,  1866. 

It  is  an  interesting  volume  that  will  amply  repay 
for  a careful  perusal  by  all  intelligent  readers. — 
Chicago  Med.  Examiner,  Feb.  1S66. 

A work  which,  like  the  present,  will  largely  aid 
the  practitioner  in  recognizing  and  arresting  the  first 
insidious  advances  of  cerebral  and  mental  disease,  is 
one  of  immense  practical  value,  and  demands  earnest 
attention  and  diligent  study  on  the  part  of  all  who 
have  embraced  the  medical  profession,  and  have 
thereby  undertaken  responsibilities  in  which  the 
welfare  and  happiness  of  individuals  and  families 
are  largely  involved.  We  shall  therefore  close  this 
brief  and  necessarily  very  imperfect  notice  of  Dr. 
Winslow’s  great  and  classical  work  by  expressing 


our  conviction  that  it  is  long  since  so  important  and 
beautifully  written  a volume  has  issued  from  the 
British  medical  press.  The  details  of  the  manage- 
ment of  confirmed  cases  of  insanity  more  nearly  in- 
terest those  who  have  made  mental  diseases  their 
special  study ; but  Dr.  Winslow’s  masterly  exposi- 
tion of  the  early  symptoms,  and  his  graphic  descrip 
tions  of  the  insidious  advances  of  incipient  insanity, 
together  with  his  judicious  observations  on  the  treat- 
ment of  disorders  of  the  mind,  should,  we  repeat,  be 
carefully  studied  by  all  who  have  undertaken  the 
responsibilities  of  medical  practice. — Dublin  Medical 
Press. 

It  is  the  most  interesting  as  well  as  valuable  book 
that  we  have  seen  for  a long  time.  It  is  truly  fasci- 
nating.— Am.  Jour.  Med.  Sciences. 

Dr.  Winslow's  work  will  undoubtedly  occupy  an 
unique  position  in  the  medico-psychological  litera- 
ture of  this  country. — London  Med.  Review. 


j^SHTON  {T.  J.) 

ON  THE  DISEASES,  INJURIES,  AND  MALFORMATIONS  OF 

THE  RECTUM  AND  ANUS;  with  remarks  on  Habitual  Constipation.  Second  American, 
from  the  fourth  and  enlarged  London  edition.  With  handsome  illustrations.  In  one  very 
beautifully  printed  octavo  volume  of  about  300  pages.  $3  25.  (Just  Issued.) 


We  can  recommend  this  volume  of  Mr.  Ashton’s  in 
the  strongest  terms,  as  containing  all  the  latest  details 
of  the  pathology  and  treatment  of  diseases  connected 
with  the  rectum. — Canada  Med.  Journ.,  March,  1866. 

One  of  the  most  valuable  special  treatises  that  the 
physician  and  surgeon  can  have  in  his  library. — 
Chicago  Medical  Examiner , Jan.  1S66. 


The  short  period  which  has  elapsed  since  the  ap- 
pearance of  the  former  American  reprint,  and  the 
numerous  editions  published  in  England,  are  the  best 
arguments  we  can  offer  of  the  merits,  and  of  the  use- 
lessness of  any  commendation  on  our  part  of  a book 
already  so  favorably  known  to  our  readers. — Boston 
Med.  and  Surg.  Journal , Jan.  25,  1S66. 


32 


Henry  C Lea’s  Publications. 


IXDEX  TO  CATALOGUE. 


Abel  and  Bloxam’s  Handbook  of  Chemistry 
' Allen’s  Dissector  and  Practical  Anatomist 
American  Journal  of  the  Medical  Sciences 
Abstract,  Half-Yearly,  of  the  Med.  Sciences 
Anatomical  Atlas,  by  Smith  and  Horner 
Ashton  on  the  Rectum  and  Anus 
Ashwell  on  Diseases  of  Females 
Brinton  on  the  Stomach 
Barclay’s  Medical  Diagnosis  . 

Barlow’s  Practice  of  Medicine 
Barwell  on  the  Joints  . 

Bennet  (Henry)  on  Diseases  of  the  Uterus 
Bennet’s  Review  of  Uterine  Pathology  , 
Bowman’s  (John  E.)  Practical  Chemistry 
Bowman’s  (John  E.)  Medical  Chemistry 
Brande  & Taylor’s  Chemistry 
Brodie’s  Clinical  Lectures  on  Surgery  . 
Brown  on  the  Surgical  Diseases  of  Women 
Buckler  on  Bronchitis  .... 
Bucknill  and  Tuke  on  Insanity 
Budd  on  Diseases  of  the  Liver 
Bumstead  on  Venereal  .... 
Carpenter’s  Human  Physiology  . 
Carpenter’s  Comparative  Physiology  . 
Carpenter  on  the  Microscope 
Carpenter  on  the  Use  and  Abuse  of  Alcohol 
Carson’s  Synopsis  of  Materia  Medica  . 
Chambers  on  the  Indigestions 
Christison  and  Griffith’s  Dispensatory 
Churchill’s  System  of  Midwifery  . 
Churchill  on  Diseases  of  Females 
Churchill  on  Puerperal  Fever 

Clymer  on  Fevers 

Colombat  de  l’Isere  on  Females,  by  Meigs 
Condie  on  Diseases  of  Children  . 

Cooper’s  (B.  B.)  Lectures  on  Surgery  . 
Cooper  (Sir  A.  P.)  on  the  Testis,  &c. 
Cullerier’s  Atlas  of  Venereal  Diseases 
Curling  on  Diseases  of  the  Testis 
Cyclopedia  of  Practical  Medicine 
Dalton’s  Human  Physiology  . 

De  Jongh  on  Cod-Liver  Oil  . 

Dewees’s  System  of  Midwifery 
Derwees  on  Diseases  of  Females 
Dewees  on  Diseases  6f  Children 
Dickson’s  Practice  of  Medicine 
Druitt’s  Modern  Surgery 
Dunglison’s  Medical  Dictionary 
Duuglison’s  Human  Physiology 
Dunglison  on  New  Remedies 
Dunglison’s  Therapeutics  and  Materia  Med 
Ellis’s  Medical  Formulary,  by  Thomas 
Erichsen’s  System  of  Surgery 
Eiichsen  on  Nervous  Injuries 
Fergussou’s  Operative  Surgery 
Flint  on  Respiratory  Organs  . 

Flint  on  the  Heart  . 

Flint’s  Practice  of  Medicine  . 

Fownes’s  Elementary  Chemistry 
Fuller  on  the  Lungs,  &c. 

Gardner’s  Medical  Chemistry 
Gibson's  Surgery  . 

Gluge’s  Pathological  Histology,  by  Leidy 
Graham’s  Elements  of  Chemistry 
Gray’s  Anatomy 
Griffith’s  (R.  E.)  Universal  Formulary  . 
Griffith’s  (J.  W.)  Manual  on  the  Blood,  &c. 
Gross  on  Urinary  Organs 
Gross  on  Foreign  Bodies  in  Air-Passages 
Gross’s  Principles  and  Practice  of  Surgery 
Gross’s  Pathological  Anatomy 
Hartshorne’s  Essentials  of  Medicine  . 
Habershon  on  Alimentary  Canal  . 
Hamilton  on  Dislocations  and  Fractures 
Harrison  on  the  Nervous  System  . 

Hoblyn’s  Medical  Dictionary 

Hodge  on  Women 

Hodge's  Obstetrics 

Hodge’s  Practical  Dissections 
Holland’s  Medical  Notes  and  Reflections 
Horner’s  Anatomy  and  Histology 
Hudson  on  Fevers,  .... 


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7 

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18 

17 
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29 

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11 
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19 

9 

9 

9 

14 

14 

18 

14 
26 
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23 
19 
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19 
29 
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13 

J3 

2S 

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2S 

15 

15 

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13 

20 
27 


Hughes  on  Auscultation  and  Percussion 
Hillier’s  Handbook  of  Skin  Diseases  . 

Jones’s  (T.  W. ) Ophthalmic  Medicine  and  Surg. 
Jones  and  Sieveking’s  Pathological  Anatomy 
Jones  (C.  Handfield)  on  Nervous  Disorders 
Kirkes’  Physiology  .... 

Knapp’s  Chemical  Technology 
Lallemand  and  Wilson  on  Spermatorrhoea 
La  Roche  on  Yellow  Fever  . 

La  Roche  on  Pneumonia,  &c. 

Laurence  and  Moon’s  Ophthalmic  Surgery 
Lawson  on  the  Eye  .... 

Laycock  on  Medical  Observation  . 

Lehmann’s  Physiological  Chemistry,  2 vols 
Lehmann’s  Chemical  Physiology  . 

Ludlow’s  Manual  of  Examinations 
Lyons  on  Fever  . . . 

Maclise’s  Surgical  Anatomy  . 

Malgaigne’s  Operative  Surgery,  by  Brittan 
Markwick’s  Examination  of  Urine 
Mayne’s  Dispensatory  and  Formulary 
Mackenzie  on  Diseases  of  the  Eye 
Medical  News  and  Library  . 

Meigs’s  Obstetrics,  the  Science  and  the  Art 
Meigs’s  Letters  on  Diseases  of  Women 
Meigs  on  Puerperal  Fever 
Miller’s  System  of  Obstetrics 
Miller’s  Practice  of  Surgery  . 

Miller’s  Principles  of  Surgery 
Montgomery  on  Pregnancy  . 

Morland  on  Urinary  Organs  . 

Morland  on  Ursemia 
Neill  and  Smith's  Compendium  of  Med.  Science 
Neligan’s  Atlas  of  Diseases  of  the  Skin 
Neligan  on  Diseases  of  the  Skin 
Prize  Essays  on  Consumption 
Parrish’s  Practical  Pharmacy 
Peaslee’s  Human  Histology  . 

Pirrie’s  System  of  Surgery  . 

Pereira’s  Mat.  Medica  and  Therapeutics,  abridged 
Quain  and  Sharpey’s  Anatomy,  by  Leidy 
Ranking’s  Abstract 
Roberts  on  Urinary  Diseases 
Ramsbotham  on  Parturition 
Reese  on  Blood  and  Urine 
Rigby  on  Female  Diseases 
Rigby's  Midwifery  . 

Rokitansky’s  Pathological  Anatomy  . 

Royle’s  Materia  Medica  and  Therapeutics 
Sargent’s  Minor  Surgery 
Sharpey  and  Quains  Anatomy,  by  Leidy 
Simon’s  General  Pathology  . 

Simpson  on  Females  .... 

Skey’s  Operative  Surgery 
Slade  on  Diphtheria  .... 

Smith  (H.  H.)  and  Horner’s  Anatomical  Atlas 
Smith  (Edward)  on  Consumption  . 

Solly  on  Anatomy  and  Diseases  of  the  Brai 
Stilly’s  Therapeutics  .... 

Salter  on  Asthma 

Tanner’s  Manual  of  Clinical  Medicine  . 

Taylor’s  Medical  Jurisprudence  . . . 

Thomas  on  Diseases  of  Females  . 

Todd  and  Bowman’s  Physiological  Anatomy 
Todd  on  Acute  Diseases  .... 

Toynbee  on  the  Ear  .... 

Wales  on  Surgical  Operations 
Walshe  on  the  Heart  .... 

Watson’s  Practice  of  Physic  . 

West  on  Diseases  of  Females 
West  on  Diseases  of  Children 
West  on  Ulceration  of  Os  Uteri 
What  to  Observe  in  Medical  Cases 
Williams’s  Principles  of  Medicine 
Wilson’s  Human  Anatomy  . 

Wilson's  Dissector 

Wilson  on  Diseases  of  the  Skin  . 

Wilson's  Plates  on  Diseases  of  the  Skin 
Wilson’s  Handbook  of  Cutaneous  Medicine 
Wilson  on  Healthy  Skin 
Wilson  on  Spermatorrhoea 
Winslow  on  Brain  and  Mind 


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30  . 
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_ 

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II 

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